[Evaluation of thromboprophylaxis in patients hospitalized in a tertiary care center: an applicable model of clinical practice evaluation. Revision of 320 cases]. / Évaluation de l'utilisation de la thromboprophylaxie chez les patients hospitalisés dans un centre hospitalier universitaire : un modèle applicable d'évaluation de la qualité de l'acte. Une revue de 320 patients hospitalisés.

OBJECTIVES: To analyze in-hospital thromboprophylaxis in patients at risk for venous thromboembolism. To evaluate compliance with heparin-induced thrombocytopenia screening recommendations in these patients. PATIENT AND METHODS: We performed a cross-sectional study of 395 patients hospitalized in our tertiary care center at risk for venous thromboembolism. We collected data regarding thromboprophylaxis (risk factors for thrombosis, type of prophylaxis, bleeding risk, demographic data, and hospitalization data). RESULTS: Three hundred and twenty patients were included in the study; 183 patients were hospitalized on medical wards and 137 patients on surgical wards. Thromboprophylaxis was indicated in 57% of the patients according to the American College of Chest Physicians' clinical practice guidelines. Adequate venous thrombosis prophylaxis was prescribed for 83.7% of these patients (76.1% of medical cases and 90.6% of the surgical cases). In contrast, only 47.1% of at risk patients on the family medicine wards received adequate prophylaxis. 79.3% of patients for whom it was indicated underwent appropriate platelet count monitoring. CONCLUSION: The use of thromboprophylaxis is well established in our institution. After having reviewed these data we instituted measures to improve our rate of appropriate thromboprophylaxis and platelet count monitoring. This type of evaluation could be considered by other centers in order to evaluate their performance and institute measures to improve their quality of care.

A simple, inexpensive, life-saving way to perform iterative laparotomy in patients with severe intra-abdominal sepsis.

Between 1 June 1993 and 31 December 1998, 17 patients underwent temporary abdominal closure with 3L urological irrigation bags, because in most cases, there was massive sepsis leading to the conclusion that primary closure was not advisable. Indicative of the seriousness of these conditions, Apache score averaged 19 (range 10-30). The technique consisted of suturing a double thickness of irrigation bags to each side of the wound, and joining the two bags in the midline with running sutures. Abdominal lavage with large quantities of fluid was performed every other day. This type of closure was used for a mean duration of 15 days. Mean length of hospitalization was 60 days. There were only three deaths (17.6%). No incisional hernia occurred after the iterative laparotomies. Deleting patients with acute pancreatitis would have reduced the death rate to only 7%. A 3L urological irrigation bag costs pound 11.60 (24.40 dollars CAN) while a Marlex mesh costs pound 81.40 (171.00 dollars CAN). We conclude that the usage of 3L urological plastic bags is a simple, safe and efficient method for temporary closure of the abdomen.

Educational collaboration and innovation. The nurse-midwifery and family nurse practitioner programs at the University of New Mexico.

The University of New Mexico College of Nursing Nurse-Midwifery and Family Nurse Practitioner programs are successfully implementing an educational program founded on a shared vision and core. The curriculum design and methods of implementation facilitate study by students distant from the College, clinical learning experiences in rural areas, and dual preparation. Shared application of faculty resources results in availing students of a variety of expertise and cost-effectiveness.

Distance education for nurse practitioners: a partial solution.

Health professionals who live and practice in rural areas have limited opportunities to further their education. In order to pursue advanced nursing degrees, nurses have to leave their communities. A collaborative distance education project involving the University of New Mexico College of Nursing, the Area Health Education Center, and Western New Mexico University has provided a partial solution to this problem. Six registered nurses living and practicing in a rural site are now receiving their Family Nurse Practitioner degrees via two-way audio/video teleconferencing equipment. Distance education can improve the numbers of primary care providers in rural areas; however, projects will require extensive planning and resources.

The moral reasoning of nurse practitioners.

This qualitative research study was conducted to describe the moral reasoning utilized by participating nurse practitioners to resolve moral dilemmas in their clinical practice. Five major essential features of moral reasoning emerged from the data: the contextual framework for moral reasoning, values, influencing factors, recognizing the dilemma, and outcomes. The interrelationship of the essential features of moral reasoning provided insight into how NPs deal with moral dilemmas as well as the role that caring and the nurse-patient relationship played as a part of the moral decision making process.

When the client is armed or dangerous: management of violent and difficult clients in primary care.

Health care settings and providers are not immune to violent or disruptive behavior by clients or by strangers off the street. Verbal abuse and threats of violence can escalate to physical attacks directed against health care practitioners. This article discusses the management of violent or dangerous patients in the primary care setting. Characteristics of potentially violent patients are reviewed, along with assessment clues useful in predicting violent behavior. Specific interventions to counteract or diffuse a potentially violent situation are proposed.

Moral dilemmas experienced by nurse practitioners.

This article details the moral dilemmas experienced by NPs in their primary care practices. From the practitioners' stories emerged strong personal and professional values that guided and shaped the resolutions to the dilemmas. The dilemmas themselves and the values of the NPs offer insight into the role of the nurse in advanced practice. Implications based on these findings for clinical practice and NP education are also discussed.

A history of nursing's code of ethics.

This article has focused on the history of the code of ethics for nurses. The changes in the code intertwine with nursing's journey toward professionalism and reflect changes in nursing, society and health care. Over the years, however, the code has remained relatively stable. Six of the statements can be traced back to the 1926 code and five others to the revision of the code in 1960. The code of ethics has provided guidance for the profession, and has helped determine nursing's position as a profession in society.

Evaluating basic nursing skills through group video testing.

The skills/assessment course is the initial clinical experience for students and they are quite naive in their role expectations. Benner (1982 and 1987) refers to the transition stages of "novice" to "expert" in nursing. Although the major focus of the group video testing situation was to solve time constraints, the incorporation of professional nursing judgment was addressed in the process. The group effort, patient scenarios, critiques, visual performance, and analysis found in the group video testing method may expedite this transition of the "novice" to "competent" and eventual "expert" practitioner.