Nursing assessments of women with hypertensive disorders during labor in an academic medical center in Mississippi: a best practice implementation project.

OBJECTIVES: The objective of this project was to promote evidence-based practices regarding the nursing assessment of pregnant women with hypertensive disorders admitted to the intrapartum unit. INTRODUCTION: Hypertension during pregnancy has been associated with adverse maternal and fetal outcomes. Ongoing evaluation and nursing care are key in the prevention of complications resulting from hypertensive disorders in pregnancy. METHODS: The implementation of this best practice project was guided by the JBI Model of Evidence-based Healthcare and used the JBI Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback strategy to promote evidence-based practices regarding the nursing assessment of pregnant women with hypertensive disorders admitted to an intrapartum unit. Eight audit criteria that were representative of best-practice recommendations for nursing assessment of pregnant women with hypertensive disorders were used. A baseline audit was conducted, followed by the implementation of multiple strategies that were determined by the key stakeholders. The project was finalized with a follow-up audit to determine a change in compliance with best-practice recommendations. RESULTS: Baseline audits revealed an average 45% compliance rate with the eight best practice audit criteria. An on-site simulation event, which included a nursing assessment of normal and abnormal lung sounds along with the hands-on practice of deep tendon reflexes, was provided by project members. Evidence-based assessment guidelines were presented and reviewed with all participants. Input from the nursing staff was gathered regarding current documentation practices and electronic health record accessibility. As a result, an electronic health record change was requested, and improvements in nursing practice were observed for five of the eight audit criteria. Follow-up audits revealed an average compliance rate of 73% for all eight audit criteria, a 28% improvement. CONCLUSION: Continuing nursing education and ongoing competency refreshers can affect the quality of client care and outcomes by offering occasions to improve or strengthen clinical expertise and proficiency. For this project, the simulation training event improved nursing staff compliance with best practices.

Rates of Venous Thromboembolism and Central Line-Associated Bloodstream Infections Among Types of Central Venous Access Devices in Critically Ill Children.

OBJECTIVES: Central venous access devices, including peripherally inserted central catheters and central venous catheters, are often needed in critically ill patients, but also are associated with complications, including central-line associated bloodstream infections and venous thromboembolism. We compared different central venous access device types and these complications in the PICU. DESIGN: Multicenter, cohort study. SETTING: One hundred forty-eight participating Virtual PICU Systems, LLC, hospital PICU sites. PATIENTS: Pediatric patients with central venous access placed from January 1, 2010, to December 31, 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient and central venous access device variables postulated to be associated with central-line associated bloodstream infection and venous thromboembolism were included. Data were analyzed using Pearson chi-square test or Fisher exact test for categorical variables, Mann-Whitney U test for continuous variables, and logistic regression and classification trees for multivariable analysis that examined significant predictors of venous thromboembolism or central-line associated bloodstream infection. Analysis included 74,196 first lines including 4,493 peripherally inserted central catheters and 66,194 central venous catheters. An increased rate of venous thromboembolism (peripherally inserted central catheter: 0.93%, central venous catheter: 0.52%; p = 0.001) (peripherally inserted central catheter: 8.65/1,000 line days, central venous catheter: 6.29/1,000 line days) and central-line associated bloodstream infection (peripherally inserted central catheter: 0.73%, central venous catheter: 0.24%; p = 0.001) (peripherally inserted central catheter: 10.82/1,000 line days, central venous catheter: 4.97/1,000 line days) occurred in peripherally inserted central catheters. In multivariable analysis, central venous catheters had decreased association with central-line associated bloodstream infection (odds ratio, 0.505; 95% CI, 0.336-0.759; p = 0.001) and venous thromboembolism (odds ratio, 0.569; 95% CI, 0.330-0.982; p = 0.043) compared with peripherally inserted central catheters. CONCLUSIONS: Peripherally inserted central catheters are associated with higher rates of central-line associated bloodstream infection and venous thromboembolism than central venous catheters in children admitted to the PICU.

Tumor necrosis factor biologics beyond psoriasis in dermatology.

INTRODUCTION: TNF-α is a cytokine essential for immune response and its receptors has been shown to be dysregulated in a variety of diseases including psoriasis vulgaris. There are a number of TNF-α inhibitors approved for psoriasis, however there is a growing body of literature supporting their use in a wide variety of dermatological conditions. AREAS COVERED: The use of biologic TNF-α antagonists in conditions for which they have not yet been approved by the FDA ('off-label' uses) and the literature that supports the most appropriate agents and conditions for use. A PubMed/MEDLINE search was performed with the keywords 'TNFα antagonist', 'biologic therapy', 'off-label' and 'unapproved'. The list of references and citing articles of the articles retrieved were also used as sources. This complete list was evaluated for inclusion, based on relevance to the proposed goal of this review. EXPERT OPINION: There are a large number of conditions for which biologic antagonists of TNFα are effective, beyond those already approved by the FDA. The various agents vary in their efficacy in treatment, with infliximab consistently the most effective, particularly in granulomatous diseases. Although effectiveness varies among these conditions, biologic antagonists of TNF-α are promising for the treatment of these diseases.