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Nurse Informaticists Address Texas Ebola Case, EHR Design Questions

October 17, 2014

By Susan McBride, PhD, RN-BC, CPHIMS, professor and program director of the Masters in Nursing Informatics Program, Texas Tech University Health Sciences Center, and Mari Tietze, PhD, RN-BC, FHIMSS, associate professor and director, Interprofessional Health IT Program at Texas Woman’s University (TWU). The views expressed are those of the authors and don’t represent those of Texas Tech or TWU.

Silo_-_height_extension_by_adding_hoops_and_staves

EHRs: information ‘siloes’ or interprofessional collaboration?

The recent Ebola case in Dallas—in which a patient was admitted to the hospital three days after he visited the ER exhibiting symptoms associated with Ebola and reporting that he’d recently traveled from West Africa—brought this global public health story close to home for many of us residing in the area. As has been widely reported, the patient died last week after nearly 10 days in the hospital.

An initial focus of media coverage was the suggestion that a failure of nursing communication had contributed to the release of the patient from the hospital on his first visit. Partly reflecting evolving explanations offered by the hospital, the media focus then shifted to a potential flaw in the hospital’s electronic health record (EHR) system, in which information recorded by a nurse about the patient’s travel history might not have been visible to physicians as well. Read the rest of this entry »

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Addressing Nurses’ Urgent Concerns About Ebola and Protective Equipment

October 15, 2014

By Betsy Todd, MPH, RN, CIC, AJN clinical editor. (See also her earlier post, “Ebola: A Nurse Epidemiologist Puts the Outbreak in Perspective.”)

This is not a time to panic. It is a time to get things right.—John Nichols, blogging for the Nation, 10/12/2014

Scanning electron micrograph of filamentous Ebola virus particles budding from an infected VERO E6 cell (35,000x magnification). Credit: NIAID

Scanning electron micrograph of filamentous Ebola virus particles budding from an infected VERO E6 cell (35,000x magnification). Credit: NIAID

For years, nurses have tolerated increasingly cheap, poorly made protective gear—one result of health care’s “race to the bottom” cost-cutting. Now the safety of personal protective equipment (PPE) is being hotly debated as the Ebola epidemic spills over into the U.S.

If all nurses had access to impermeable gowns that extended well below the knee (and could be securely closed in back, had real cuffs, and didn’t tear easily); faceguards that completely shielded; N95 respirator masks that could be properly molded to the face; and disposable leg and shoe covers, we might not be having the same conversation. Yet how much protection can we count on from the garb we now have available, especially considering the minimal donning and doffing training given to most nurses?

While there is more to be learned about possible “outlier” modes of Ebola transmission, it’s pretty clear from past experience (including recent Ebola hospitalizations at Emory University Hospital and the University of Nebraska Medical Center, where no transmission has occurred) that standard, contact, and droplet precautions will virtually always prevent Ebola virus transmission. Because of the theoretical possibility that the virus could be aerosolized during procedures like intubation or suctioning, airborne precautions are usually added. (And from what we’ve seen, they’re being followed routinely, and not used only during aerosolizing procedures.)

Many organizations, including National Nurses United, are calling for hazmat-type gear and PAPR hoods (powered air-purifying respirators, which are HEPA-filtered) for staff who care for Ebola patients. Because most nurses have not used these, this more complex gear presents new challenges, especially because of the potential for self-contamination when worn and removed by untrained staff.

Specific techniques for donning and doffing PPE are not new, but many nurses have never been taught to pay attention to these details. One has only to look at staff in a contact precautions room, only half covered by their untied gowns, to understand why resistant organisms continue to spread within hospitals. Many clinicians may not have believed that their cavalier attitude towards PPE had anything to do with the next patient’s nosocomial MRSA pneumonia. During this Ebola epidemic, though, we are quickly learning that the proper use of PPE is a matter of life and death—ours. Read the rest of this entry »

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Planning Postdischarge Care with Cognitively Impaired Adults

October 15, 2014
McCauley

A patient performs the CLOX 1, a clock-drawing task used to assess patients for cognitive impairment. Photo by Ed Eckstein.

By Shawn Kennedy, AJN editor-in-chief

The transition from hospital to home can be fraught with pitfalls, especially if the patient in question is an older adult with multiple conditions and a not-so-prepared caregiver. The transitional care model, in which NPs coordinate care and provide follow-up care after discharge, has been shown to be successful in reducing hospital readmissions in this group of patients.

With Medicare levying penalties on hospitals with higher-than-average readmissions rates, the stakes aren’t just high for patients and their families. Might similar models of care also work with cognitively impaired adults?

In “Studying Nursing Interventions in Acutely Ill, Cognitively Impaired Older Adults,” a feature article in AJN‘s October issue (free until the end of October), Kathleen McCauley and colleagues from the University of Pennsylvania seek to answer this question, among others.

In the article, McCauley and colleagues describe the methodology and protocols used in their study, summarize their findings, and discuss some of the challenges in conducting research in the clinical setting. Among their findings is the important lesson that research involving cognitively impaired older adults must actively engage clinicians, patients, and family caregivers, as well as the need for hospitals to make cognitive screening of older adults who are hospitalized for an acute condition “a standard of care.” Read the rest of this entry »

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Resisting the Rising Tide of Parkinson’s

October 13, 2014
By Barbara Hranilovich. All rights reserved.

By Barbara Hranilovich. All rights reserved.

The Reflections essay in the October issue of AJN is called “After-Dinner Talks.” These are talks with a purpose, a form of physical therapy with high stakes. Writes the author, Minter Krotzer, of her husband’s long struggle with Parkinson’s disease: “Hal always says Parkinson’s is not his identity, and it isn’t, as long as he doesn’t let it claim him, or as long as it doesn’t claim us.”

Here’s an excerpt from the beginning:

‘I’d like you two to have a conversation every night after dinner,’ Hal’s speech therapist said to us.

. . . . Over the years, Hal’s Parkinson’s disease has made him difficult to understand. His vocal cords have restricted movement and it is hard for him to make it to the end of a sentence. He often swallows his last words or they just barely come out. Sometimes he sounds like he is underwater—the words indistinguishable from one another, blurry and pitchless.

But read the short essay, which is free. In just one page it manages to say a lot about chronic illness and the constant, conscious effort it can require of both patients and family members; about a clinician’s good advice; about marriage and communication; and about the power of language to keep us human.—Jacob Molyneux, senior editor.

Illustration by Barbara Hranilovich; all rights reserved.

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Calciphylaxis: The Intriguing Case of Ms. W.

October 10, 2014
Ms. W. post-recovery, with her husband

Ms. W. post-recovery, with her husband

By Sylvia Foley, AJN senior editor

“I survived, although I had been told that I’d eventually die from infection in the wounds.”

In one of this month’s two CE features, “Calciphylaxis: An Unusual Case with an Unusual Outcome,” Tina Wangen and colleagues report on the intriguing story of L.W., a 40-year-old patient who, aside from being female, had no other known risk factors for the disease. Here’s an overview of the article:

Calciphylaxis is most common in patients with end-stage renal disease, and hyperparathyroidism is often present as well. But several cases in patients with normal renal and parathyroid function have been reported; this article describes one such case. The etiology and pathophysiology of calciphylaxis aren’t well understood. There are many risk factors, and the reported median survival time is 2.6 months after diagnosis. The condition is characterized by isolated or multiple lesions that progress to firm, nonulcerated plaques and then to ischemic skin necrosis and ulceration.
In August 2010, a female patient arrived at the hospital with multiple deep, painful necrotic wounds. Given this patient’s presentation on admission, the nurses kept expecting the physicians to initiate end-of-life discussions with her and were surprised when this did not happen. After five days, the patient was diagnosed with calciphylaxis in the unusual presentation of normal renal and parathyroid function, and the team realized that her chances for survival were greater than expected. The nursing staff was crucial in developing and implementing an intensive treatment plan. The patient survived and made a full recovery.

Treatment. The authors describe the various treatment options for calciphylaxis, which are limited. Ms. W. underwent surgical debridement; anti-infection measures that included the use of wet-to-moist dressings, topical antiseptics, and whirlpool baths; hyperbaric oxygen therapy; and extensive physical therapy. Her plan of care also included pain and anxiety management and nutritional support. Read the rest of this entry »

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How Do You Want to Be Cared For?

October 8, 2014
The patient in the next bed by mynameisharsha  / Harsha K R, via Flickr

The patient in the next bed by mynameisharsha / Harsha K R, via Flickr

By Betsy Todd, MPH, RN, CIC, AJN clinical editor

How do you want to be cared for?

Have you written your own personal nursing care plan? I’m not asking about your health care proxy or living will; most nurses have seen enough disastrous end-of-life scenarios to understand the need for formal advance directives. But if you become comatose or unable to communicate, what small pleasures would ease your suffering? What sights and sounds would promote healing for you, or ease your dying?

I’m often dismayed by the thoughtlessness of some staff regarding what their patients see and hear. Nurses will tune an unconscious patient’s television to the staff’s favorite soap opera, or blast the music of their own choice from the patient’s radio. I’ve witnessed staff talking on cell phones, and even arguing loudly with other staff, as though the person in the bed weren’t even there. When did we lose our attentiveness to patients as unique individuals? Read the rest of this entry »

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As Sepsis Awareness Increases and Guidelines Change, Timing Remains Crucial

October 6, 2014

By Amanda Anderson, a critical care nurse and graduate student in New York City who is currently doing a graduate placement at AJN two days a week.

stopwatch/wikimedia commons

stopwatch/wikimedia commons

September was Sepsis Awareness Month, but the urgency of the issue didn’t disappear when the month ended. I still remember my first day in the medical intensive care unit (MICU) I’d soon call home. I was shadowing the charge nurse, and an admission had just come in from the ED.

“Here, we need a CVP setup.” A crinkly bag of normal saline and a matching package containing something evidently important were shoved into my hands—a medical football passed to the only open player.

Very quickly, I would learn what a CVP, or central venous pressure, was and to monitor it. I would learn all about sepsis, and septic shock, and the treatment of its devastating process. Multiple organ dysfunction syndrome (MODS) was a primer for my care in this unit, and on my first day off of orientation, I was entrusted with one of its full-blown victims: Septic shock from pneumonia, causing respiratory, renal, and heart failure. Learning to spike a bag of saline for a CVP transducer was just my first step into the vast and complicated land of sepsis management.

This was 2007. Sometimes, as in all hospitals, care was delayed and septic patients sat without timely treatment for hours. Back then, we tubed people, snowed people, and flooded people. Now, after two updates to the Surviving Sepsis Campaign’s guidelines, we sometimes tube them, and sometimes we don’t. We use a lot less sedation, and a lot less fluid.

If you’re not familiar with them, it’s a good time to review the updated guidelines. The Surviving Sepsis Campaign Web site offers everything from exhaustive articles to handy cheat-sheets on how to handle patients from the ED who have sepsis in a manner that complies with updated guidelines. Timely sepsis recognition doesn’t just depend on ED nurses or those in the ICU; every nurse needs to know what to look for, as demonstrated by the case in this AJN article, “Recognizing Sepsis in the Adult Patient” (free until November 1).

Timing remains crucial. In the new guidelines, you’ll find a lot of the same treatment goals and procedures, but a lot more stress on rapid recognition and on doing things quickly and in the right order. Timing is so central that the campaign bundled its guidelines into time segments: 3-hour bundle and 6-hour bundle.

For example, within the first three hours, practitioners must draw blood cultures, determine lactate level, hang broad-spectrum antibiotics, and begin fluid resuscitation with a crystalloid. By the time six hours have passed, 30ml/kg of normal saline must be completed, and if the patient’s mean arterial pressure and urine output don’t meet certain parameters, vasopressor infusion (norepinephrine first, please!) must be started.

Close attention to the effectiveness of these basic measures—diagnosis, antibiotics, resuscitation, and stabilization—is key. Other more complex treatment measures such as mechanical ventilation and renal replacement therapy are addressed, but the focus remains on timing and simplicity in care.

 

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