Description of Pharmacogenomic Testing Among Patients Admitted to the Intensive Care Unit After Cardiovascular Surgery.

BACKGROUND: Pharmacogenomic (PGx) testing has the potential to provide information on specific drug-metabolizing enzymes that may lead to an absence, reduction, or increase in medication effect in patients. There is a paucity of prospective studies examining PGx testing in the intensive care unit (ICU) setting. RESEARCH AIMS: To (1) obtain a PGx panel in a sample of cardiovascular (CV) surgical patients with a planned ICU stay and identify phenotypes, and (2) identify PGx variants that may inform treatment regimens and may warrant prescribing adjustments. DESIGN AND METHODS: Descriptive, single cohort cross-sectional design. Adult (≥18 years) CV patients with an anticipated postoperative ICU stay were enrolled from a large Midwestern tertiary academic medical center. Eligible patients provided informed consent at the time of their CV clinic appointment; PGx testing was then ordered. Pharmacogenomic testing consisted of the Focused Pharmacogenomics panel which included 10 genes and 55 medications. RESULTS: Of the 272 patients screened, 100 (68% male) patients completed PGx testing (mean age 66.2 ± 9.6 years, mean Acute Physiology, Age and Chronic Health Evaluation III score 76.1 ± standard deviation). Pharmacogenomic results were available in the medical record within a median of 52.4 hours (interquartile range: 33.4-80.3). Pharmacogenomic testing results identified 5 CYP2C19 poor metabolizers, 26 CYP2C19 rapid metabolizers, 5 CYP2C19 ultrarapid metabolizers, 6 CYP2D6 poor metabolizers, 5 CYP2D6 poor to intermediate metabolizers, and 2 CYP2D6 rapid metabolizers identified. Overall, 98% of patients had actionable or potentially actionable PGx results, including 82% for warfarin, 65% for propafenone, 65% for tramadol, 46% for oxycodone, 45% for metoprolol, 33% for clopidogrel, 32% for proton pump inhibitors, 25% for statins, and 12% for haloperidol. CONCLUSIONS: A significant portion of patients had identified genetic variants that may warrant changes in medication management during and after CV-ICU stay. It remains to be seen if PGx testing leads to improvements in ICU patient outcomes.

Change-of-Shift Nursing Handoff Interruptions: Implications for Evidence-Based Practice.

BACKGROUND: The importance of change-of-shift handoffs in maintaining patient safety has been well demonstrated. Change-of-shift handoff is an important source of data used in surveillance, a nursing intervention aimed at identifying and preventing complications. Surveillance requires the nurse to acquire, process, and synthesize information (cues) encountered during patient care. Interruptions in handoff have been observed but there is a gap in the evidence concerning how interruptions during nurse-to-nurse handoff impact the change-of-shift handoff process. AIMS: To describe registered nurses' perceptions of interruptions experienced during change-of-shift handoff at the bedside in critical care units and analyze the number, type, and source of interruptions during change-of-shift handoff at the bedside. METHODS: An exploratory descriptive design was used. One hundred nurse-to-nurse handoffs were observed, and four focus groups were conducted. Observation data were analyzed with descriptive statistics and quantitative content analysis. Focus group data were analyzed with qualitative content analysis. RESULTS AND FINDINGS: Of the 1,196 interruptions observed, 800 occurred in the communication between the two nurses involved in the handoff. Over 80% (645) of these interruptions were from the nurse receiving handoff and included questions or clarification of information received. About half of the nurses reported that interruptions occurred during handoff. Focus group findings revealed that whether or not something is an interruption is determined by the individual nurse's appraisal of value added to their knowledge of the patient and/or plan of care at the time of handoff. LINKING EVIDENCE TO ACTION: Interruptions during handoff are evaluated as useful or disruptive based on the value to the nurse at the time. Strict structuring or mandating of handoff elements may limit nurses' ability to communicate information deemed most relevant to the care of a specific unique patient.

Standardized Change-of-Shift Handoff: Nurses' Perspectives and Implications for Evidence-Based Practice.

BACKGROUND: Nursing handoff is a communication activity with a high risk for loss or omission of information. Efforts to improve handoffs include standardization of the processes and content of handoff communications. OBJECTIVES: To examine nurses' perspectives on the structure and organization of change-of-shift handoffs. METHODS: A qualitative descriptive approach was used to conduct a secondary analysis of focus group data. Thirty-four nurses from 4 critical care units participated in focus groups. RESULTS: Three themes emerged: handoff elements are defined by practice and culture; a clear, consistent, identified structure supports handoff; and personal preferences can disrupt handoff. CONCLUSIONS: A standardized approach to handoff based on unit and organizational needs will be more successful than a broad mandate of content and organization. Individual preference is prevalent and strongly influences the information conveyed and the structure of handoff communication.

Outcomes of a Dignity Therapy/Life Plan Intervention for Patients With Advanced Cancer Undergoing Chemotherapy.

Dignity therapy is a psychosocial intervention provided at the end of life to improve patient outcomes, but many persons cannot complete it because of health decline. Patients also reprioritize their life plans as death becomes imminent. As part of meeting standards to provide psychosocial palliative care simultaneously with cancer treatment, we provided a dignity therapy/life plan intervention to 18 patients with advanced pancreatic or lung cancer receiving cancer treatment. The study aim was to evaluate patient-reported outcomes of dignity therapy/life plan. Dignity therapy entailed interviews during 3 outpatient oncology encounters, which then became a legacy document for family. Participants documented life goals as their life plan. Distress, quality of life, spirituality, dignity, and purpose in life were measured at baseline, immediately after intervention, and 3 months later. No variables were significantly different from baseline to postintervention and 3 months later, except for less distress between baseline and 3 months (P = .04). Although this intervention did not show improvements in outcomes, patients with advanced disease receiving active treatment typically experience worsening symptoms overall. Maintaining psychosocial outcomes may be preventing further morbidity in an advanced cancer population during treatment and bears further exploration. Given our small sample size, further research is warranted.

Feasibility and Acceptability of a Dignity Therapy/Life Plan Intervention for Patients With Advanced Cancer.

PURPOSE/OBJECTIVES: To determine the feasibility and acceptability of a dignity therapy/life plan intervention in the outpatient oncology setting.
. RESEARCH APPROACH: Pilot descriptive study.
. SETTING: Outpatient clinic in a tertiary oncology center. 
. PARTICIPANTS: 18 patients within 12 months after diagnosis undergoing treatment for advanced pancreatic cancer or non-small cell lung cancer.
. METHODOLOGIC APPROACH: Patients received dignity therapy, consisting of a focused life review/values clarification interview session and two subsequent sessions to produce a generativity document, which they can use later as they wish. Participants also wrote a life plan, in which they listed future hopes and dreams. Intervention feasibility and acceptability for patients and oncology clinician satisfaction were assessed.
. FINDINGS: Among the 18 patients completing the intervention, almost all felt it was worthwhile, would do it again, had their expectations met or exceeded, would recommend it to others, and said the timing was just right.
. INTERPRETATION: This psychosocial intervention was found to be feasible and acceptable to patients with cancer undergoing active treatment.
. IMPLICATIONS FOR NURSING: Nurses may be in an ideal position to offer a dignity therapy/life plan intervention to patients with advanced cancer during treatment.