Impact of the utilization of 500 mL IV bags on crystalloid resuscitation volumes administered to trauma patients.

INTRODUCTION: Administering large volumes of crystalloids to trauma patients has been shown to exacerbate metabolic complications of hemorrhage including dilutional coagulopathy and worsening acidosis The aim of this study was to evaluate crystalloid administration volumes in trauma patients after replacing 1 L IV containers with 500 mL IV containers in the emergency department trauma resuscitation bay. MATERIALS AND METHODS: This was a single-center, IRB-approved, retrospective cohort evaluation of adult trauma patients conducted at an 864-bed community tertiary referral center located in the southeastern United States. Patterns of crystalloid administration were examined before and after the trauma resuscitation bay began to exclusively stock 500 mL IV containers. The primary outcome was mean total crystalloid volume infused from time of injury to hospital admission. Secondary outcomes included mean total crystalloid volume infused prior to administration of blood products, proportion of patients who received less than 2 L total of crystalloids, time to initiation of blood products, and mortality in both the emergency department and in-hospital. RESULTS: Patient characteristics were largely similar between both groups including age, mechanism of injury, and Injury Severity Score. For the primary outcome, the mean total crystalloid volume infused from time of injury to hospital administration, patients in the 500 mL IV fluid container group were administered 555 mL less crystalloid when compared to the 1 L IV fluid container group, 1048 mL vs 1603 mL (p < 0.01; 95% CI 406 mL - 704 mL), respectively. After conversion to the 500 mL IV container bags, there was a 27.5% increase in the proportion of patients receiving less than 2 L of crystalloid, 90.5% vs 63.0% in the 500 mL IV fluid container and 1 L IV fluid container groups, respectively (p < 0.01). CONCLUSIONS: Due to reduced mortality, expanding literature and guidelines clearly support minimizing IV crystalloid resuscitation. Institutions must now work to minimize use of IV crystalloids to hemorrhaging trauma patients and a simple solution of using smaller IV fluid bags was shown to improve adherence to this practice.

Manual vs Automatic Prone Positioning and Patient Outcomes in Acute Respiratory Distress Syndrome.

BACKGROUND: Prone positioning is a standard treatment for moderate to severe acute respiratory distress syndrome (ARDS), but the outcomes associated with manual versus automatic prone positioning have not been evaluated. OBJECTIVE: To retrospectively evaluate outcomes associated with manual versus automatic prone positioning as part of a pronation quality improvement project implemented by a multidisciplinary team. METHODS: A retrospective, descriptive-comparative approach was used to analyze data from 24 months of a prone positioning protocol for ARDS. The study involved 37 patients, with 16 undergoing manual and 21 undergoing automatic prone positioning. Descriptive and nonparametric statistical analyses were used to evaluate outcomes associated with manual versus automatic prone positioning. RESULTS: Outcomes were similar between the 2 groups regarding time to initiation of prone positioning, discharge disposition, and length of stay. Manually pronated patients were less likely to experience interruptions in therapy (P = .005) and complications (P = .002). Pressure injuries were the most common type of complication, with the most frequent locations in automatically pronated patients being the head (P = .045), thorax (P = .003), and lower extremities (P = .047). Manual prone positioning resulted in a cost avoidance of $78 617 per patient. CONCLUSION: Manual prone positioning has outcomes similar to those of automatic prone positioning with less risk of interruptions in therapy, fewer complications, and lower expense. Further research is needed to determine whether manual prone positioning is superior to automatic prone positioning in patients with ARDS.

Ultrasound-Guided Peripheral Intravenous Catheter Insertion: The Nurse's Manual.

Peripheral intravenous catheter placement is a skill that is used daily in the hospital. However, many nurses face the challenge of cannulating increasingly complex and difficult-to-access vasculature. Although emergency department clinicians have been using ultrasound to facilitate this procedure for the last 18 years, ultrasound-guided peripheral intravenous catheter placement has not been as rapidly adopted in the critical and acute care nursing realms. Given the benefits of this procedure, including increased patient satisfaction and reduced use of central catheters, its use should be encouraged among all acute care clinicians. The aim of this article is to provide the bedside nurse with a basic understanding of the techniques involved in placing ultrasound-guided peripheral intravenous catheters in patients with difficult venous access.

Inpatient Nurses' Perception of Workplace Violence Based on Specialty.

OBJECTIVE: The aim of this study was to evaluate the impact of inpatient nursing specialties on the perceptions of workplace violence. BACKGROUND: The association between nursing specialty and the perception of workplace violence has not been identified. METHODS: An evaluation of inpatient nurses' perceptions of workplace violence at a single health system was conducted using a modified Survey of Violence Experienced by Staff instrument. RESULTS: Of the respondents, 87.2% experienced workplace violence, of which 96.3% was patient related. Patient-initiated verbal abuse, threats, and physical assault frequency differed significantly based on specialty. Post hoc comparisons further elucidate the differences in specialty populations. CONCLUSION: Workplace violence is a nursing concern; however, the frequency in which workplace violence occurs differs based on specialty. The frequency of threats and injuries to nursing staff was significantly higher in medical and trauma units.

An evolutionary concept analysis of futility in health care.

AIM: To report a concept analysis of futility in health care. BACKGROUND: Each member of the healthcare team: the physician, the nurse, the patient, the family and all others involved perceive futility differently. The current evidence and knowledge in regard to futility in health care manifest a plethora of definitions, meanings and interpretations without consensus. DESIGN: Concept analysis. DATA SOURCES: Databases searched included Medline, Cumulative Index of Nursing and Allied Health Literature, Academic Search Premier, Cochrane Database of Systematic Reviews and PsycINFO. Search terms included "futil*," "concept analysis," "concept," "inefficacious," "non-beneficial," "ineffective" and "fruitless" from 1935-2016 to ensure a historical perspective of the concept. A total of 106 articles were retained to develop the concept. METHODS: Rogers' evolutionary concept analysis was used to evaluate the concept of futility from ancient medicine to the present. RESULTS: Seven antecedents (the patient/family autonomy, surrogate decision-making movement, the patient-family/physician relationship, physician authority, legislation and court rulings, catastrophic events and advancing medical technology) lead to four major attributes (quantitative, physiologic, qualitative, and disease-specific). Ultimately, futile care could lead to consequences such as litigation, advancing technology, increasing healthcare costs, rationing, moral distress and ethical dilemmas. CONCLUSION: Futility in health care demonstrates components of a cyclical process and a consensus definition is proposed. A framework is developed to clarify the concept and articulate relationships among attributes, antecedents and consequences. Further testing of the proposed definition and framework are needed.

Decreasing Peripherally Inserted Central Catheter Use With Ultrasound-Guided Peripheral Intravenous Lines: A Quality Improvement Project in the Acute Care Setting.

An ultrasound-guided peripheral intravenous (UGPIV) quality improvement project occurred in an 849-bed tertiary care hospital with a goal to reduce the use of central lines, in particular, peripherally inserted central catheters (PICCs). Since implementation, PICCs have decreased by 46.7% overall, and 59 nurses in-hospital are competent in placing UGPIVs. Placement of UGPIVs by the bedside nurse is a key initiative in decreasing PICC use and, potentially, infections.