Patients In Acute Care Setting Research Articles

Noninvasive Positive Pressure Ventilation

Noninvasive ventilation has become a widespread tool of treatment and support for patients in acute care settings. The treatment is used for various clinical conditions, particularly chronic obstructive pulmonary disease and acute cardiogenic pulmonary edema. The utilization of a simple nursing care checklist allows treatment in a systematic fashion. This article discusses the respiratory features of this topic: criteria for noninvasive ventilation, choice of the interface for acute clinical conditions, ventilators and modes of ventilation in noninvasive ventilation, management of setting parameters, patient/ventilator interactions, and monitoring.

Zinc: An Essential Trace Element for Parenteral Nutrition

Zinc is an essential trace element for human nutrition that is an integral part of many enzyme systems, including DNA polymerase complex. Zinc deficiency has been associated with stunting of growth and sexual immaturity. In children, deficiency causes a fatal condition called acrodermatitis enteropathica. The same syndrome has been observed in patients on total parenteral nutrition (TPN) who do not receive zinc. In TPN the requirements have been estimated by balance studies to be 3 mg/d in patients without gastrointestinal losses and a mean of 12 mg/d in patients with diarrhea and fistula losses.

Skin care strategies to prevent pressure ulcer for patients in acute care settings: a systematic review

Skin care strategies to prevent pressure ulcer for patients in acute care settings: a systematic review

Skin care strategies to prevent pressure ulcer for patients in acute care settings: a systematic review.

Objective The objective of this systematic review is to identify the best available evidence for the effectiveness of skin care interventions in preventing pressure ulcer amongst patients in acute care settings. Review Question How effective are skin care interventions to prevent pressure ulcer in adults (18 years old) when compared with standard practice or no intervention? Criteria for Considering Studies for this Review Population The review will consider all studies that involved adult patients (more than or equal to 18 years old) in acute care hospitals. Since the prevalence of pressure ulcer is considerably high in acute care, the patients admitted to acute care settings will be included in this review. Patients in long-term care, rehabilitation centre and nursing homes will be excluded in the review. Moreover, this review will exclude patients who have pre-existing pressure ulcer. Intervention This review will identify the skin care in preventing pressure ulcers. The skin care is usually performed by nurses in hospitals. Types of the interventions are massage, skin inspection, skin dressing and providing skin topical (moisturizer, powder and solutions).23 Other types of prevention such as risk assessment, repositioning, using support surface, risk assessment, educational program and supplementation of nutrition will be excluded in the interventions. Comparison The comparison of the review will be standard care or no intervention. Outcome Patients do not develop grade one pressure ulcer will be consider as a primary outcome in this review. The stage is based on grading scale from National Pressure Ulcer Advisory Panel NPUAP.2 In addition, the outcome is measured by skin assessment using any scale such as Norton scale, Waterlow Scale, Braden Scale or nurse clinical judgement.21 The secondary outcome will be the length of stay in hospital.

The Effectiveness and Feasibility of human roles and systems involved in routine medication administration systems and processes to prevent medication incidents in acute care settings: a systematic review

Objectives The overall objective is to investigate what human roles and systems are most effective and feasible for preventing medication incidents during routine medication administration in hospital-based acute care settings. The review will consider the effectiveness and feasibility of the following interventions in preventing medication incidents: • Timing of administration • Type and dosage of drug • Route of administration • Type of patient • Type of staff Member, for example nurse • Type of acute care setting • Drug delivery and storage • Dispensing system Inclusion Criteria Types of participants The participants in this review will consist of: hospital- based acute care setting nurses, pharmacists, pharmacy technicians, medical and surgical staff in acute care settings and adult patients in acute care settings. Types of interventions This review examines two major types of intervention: Administration systems • Self administration • Trolley systems • Single unit systems • Pharmacy to ward systems Administration processes • Documentation/recording • Drug types • Prescribing • Single nurse administration • Multiple nurse administration • Level/role of nurse • Patient involvement Types of outcome measures There are three types of outcome measures: Medication incident rate Hospital staff and adult patient satisfaction with medication administration system and process Practicality/applicability of medication administration system and process

Job characteristics and work organization factors associated with patient-handling injury among nursing personnel

The aim of this cross-sectional study was to explore the association of worker characteristics and work organization factors with prevalence of patient-handling injury among nursing personnel in an acute-care inpatient setting. Self-administered questionnaires (n = 585) captured worker characteristics and patient-handling injuries within the previous 6 months. Karasek's Job Content Questionnaire measured work organization factors, including job strain (high psychological demand, low decision latitude). We created a novel measure (job strain(PHYSICAL)) reflecting high physical demand and low decision latitude, providing a more direct physiologic link to our outcome. Log-binomial regression was used to calculate prevalence ratios (PR) and 95% confidence intervals (CI). Patient-handling injuries were prevalent (35%), and incident reports were filed infrequently for injuries receiving medical care. Prevalence of injury was higher among aides compared to nurses [adjusted PR 1.4, 95%CI (1.1-1.8)] as well as among those with high [adjusted PR 1.6, 95%CI (1.2-2.4)] or mid [adjusted PR 1.9, 95%CI (1.4-2.7)] levels of job dissatisfaction. The novel definition of job strain (job strain(PHYSICAL): high physical demand, low decision latitude) was more strongly associated with patient-handling injury than the traditional definition of job strain (high psychological demand, low decision latitude). These findings add to a growing body of literature on the highly contextual nature of work organization factors.

Nurses’ descriptions of changes in cognitive function in the acute care setting

Objective: To describe nurses’ documentation of cognition and behavioural changes in patients in acute care settings. Hospitalised patients often present with multiple co‑morbidities including declining levels of cognitive functioning and this is particularly so for older people. Many older people will experience a delirium during hospitalisation. While prevention or prompt management of delirium is paramount to providing quality care, research suggests that health professionals regularly fail to differentiate between delirium and other cognitive changes in hospitalised patients. Design: Four audits of progress notes were completed over a four week period at a Western Australian tertiary hospital to identify, quantify and categorise cognitive and behavioural changes in hospitalised patients. This paper describes data on nurses’ documentation collected in the course of those audits. On four consecutive Thursdays, the medical records of all patients identified by nursing staff as being confused were reviewed. Where no definitive cause for the confusion was documented, the case notes were examined for evidence of risk factors to determine a probable cause. Setting: A Western Australian tertiary hospital. Subjects: The medical records of all patients identified by nursing staff as being confused. Main outcome measures: Documentation in patient medical records of a patient having cognitive or behavioural changes or being confused; use of a cognitive screening tool; or a diagnosis of delirium. Results: A total of 1209 patients were surveyed over the four audit days with 183 patients (15%) being identified as confused. ‘Confusion’ was the most common descriptor used by nurses to describe cognitive and behavioural changes; in many cases it was the only term used. Many of these changes were indicative of delirium. Little use by any health professional of cognitive screening tools was found. Conclusion: Cognitive and behavioural changes are a common problem in hospitalised patients who are elderly. The use of the term confusion to describe a range of cognitive and behavioural changes is a barrier to accurate identification of delirium, which is often the first indicator of serious underlying illness.

The pediatric electrocardiogram: Part I: Age-related interpretation

Emergency physicians attending to pediatric patients in acute care settings use electrocardiograms (ECGs) for a variety of reasons, including syncope, chest pain, ingestion, suspected dysrhythmias, and as part of the initial evaluation of suspected congenital heart disease. Thus, it is important for emergency and acute care providers to be familiar with the normal pediatric ECG in addition to common ECG abnormalities seen in the pediatric population. The purpose of this 3-part review will be to review (1) age-related changes in the pediatric ECG, (2) common arrhythmias encountered in the pediatric population, and (3) ECG indicators of structural and congenital heart disease in the pediatric population.

Pathophysiology, Diagnosis, and Treatment of Orthostatic Hypotension and Vasovagal Syncope

Orthostatic hypotension (OH) occurs in 0.5% of individuals and as many as 7-17% of patients in acute care settings. Moreover, OH may be more prevalent in the elderly due to the increased use of vasoactive medications and the concomitant decrease in physiologic function, such as baroreceptor sensitivity. OH may result in the genesis of a presyncopal state or result in syncope. OH is defined as a reduction of systolic blood pressure (SBP) of at least 20 mm Hg or diastolic blood pressure (DBP) of at least 10 mm Hg within 3 minutes of standing. A review of symptoms, and measurement of supine and standing BP with appropriate clinical tests should narrow the differential diagnosis and the cause of OH. The fall in BP seen in OH results from the inability of the autonomic nervous system (ANS) to achieve adequate venous return and appropriate vasoconstriction sufficient to maintain BP. An evaluation of patients with OH should consider hypovolemia, removal of offending medications, primary autonomic disorders, secondary autonomic disorders, and vasovagal syncope, the most common cause of syncope. Although further research is necessary to rectify the disease process responsible for OH, patients suffering from this disorder can effectively be treated with a combination of nonpharmacologic treatment, pharmacologic treatment, and patient education. Agents such as fludrocortisone, midodrine, and selective serotonin reuptake inhibitors have shown promising results. Treatment for recurrent vasovagal syncope includes increased salt and water intake and various drug treatments, most of which are still under investigation.

Antimicrobial stewardship and the role of pharmacokinetics–pharmacodynamics in the modern antibiotic era

Antimicrobial stewardship, a term coined by Dale Gerding, is defined as the optimal selection, dose, and duration of an antimicrobial that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance development. Methods to promote and ensure good antimicrobial stewardship have been implemented and studied, and have typically provided tangible benefits in terms of a reduction in overall or targeted antimicrobial usage and resistance emergence. Although most of the programmatic antimicrobial stewardship efforts have been conducted in acute care inpatient settings, some strategies usually involving education have been evaluated in the outpatient venue. In this review, we shall discuss issues related to why antimicrobial stewardship is of particular importance in the modern antibiotic era. In addition, general pharmacokinetic–pharmacodynamic (PK–PD) concepts will be reviewed and specific PK–PD analyses that support the optimal selection, dosing, and duration of therapy for β-lactam antimicrobials will be provided.

The Effectiveness and Feasibility of routine IV medication administration systems and processes to prevent medication incidents in acute care settings: a systematic review

Review Objectives: To investigate what systems and processes, for routine IV medication administration in acute care settings, are most effective and feasible in preventing medication incidents. Criteria for considering studies for this review: Types of participants: Acute care nurses, pharmacists, pharmacy technicians, medical and surgical staff in acute care settings, patients in acute care settings. Types of interventions: Administration systems IT systems Human systems Administration processes Documentation/recording Drug types Prescribing Single nurse administration Multiple nurse administration Level/role of nurse Patient involvement Types of outcome measures: Medication incident rate Satisfaction with system and process Practicality/applicability of system and process

Addressing Measurement Error Bias in Nurse Staffing Research

To assess the extent of measurement error bias due to methods used to allocate nursing staff to the acute care inpatient setting and to recommend estimation methods designed to overcome this bias. Secondary data obtained from the California Office of Statewide Health Planning and Development (OSHPD) and the Centers for Medicare and Medicaid Services' Healthcare Cost Report Information System for 279 general acute care hospitals from 1996 to 2001. California OSHPD provides detailed nurse staffing data for acute care inpatients. We estimate the measurement error and the resulting bias from applying different staffing allocation methods. Estimates of the measurement errors also allow insights into the best choices for alternate estimation strategies. The bias induced by the adjusted patient days method (and its modification) is smaller than for other methods, but the bias is still substantial: in the benchmark simple regression model, the estimated coefficient for staffing level on quality of care is expected to be one-third smaller than its true value (and the bias is larger in a multiple regression model). Instrumental variable estimation, using one staffing allocation measure as an instrument for another, addresses this bias, but only particular choices of staffing allocation measures and instruments are suitable. Staffing allocation methods induce substantial attenuation bias, but there are easily implemented estimation methods that overcome this bias.

Nurses’ experiences of caring for culturally diverse patients in an acute care setting

Identification of nurses’ experiences of caring for culturally diverse patients in acute care settings contributes to transcultural nursing knowledge. This qualitative study aims to describe nurses’ experiences of caring for culturally diverse adult patients on medical and surgical wards in an acute care setting. These experiences identify current practice and associated issues for nurses caring for culturally diverse clients. A purposive sample of ten registered nurses was interviewed and transcripts analysed. Main findings were acquiring cultural knowledge, committing to and engaging with culturally diverse patients. Strategies for change developed from these findings focus on increasing cultural competency of nurses by: implementing a formal education program; developing partnerships with patients and their families to increase cultural comfort; and increasing organisational accommodation of the culturally diverse with policy review and extension of resources. Further research to explore issues for bilingual nurses and to describe the experiences of culturally diverse patients and their families in general acute care settings is recommended.

Jordanian nurses’ attitudes toward older patients in acute care settings

To identify and describe Jordanian nurses' attitudes toward older patients in acute care settings. The effects of socio-demographics and nursing work characteristics on nurses' attitudes were also examined. Descriptive correlational design was used. Kogan's (1961) Attitudes Toward Old People Scale was administered to a total population of Jordanian nurses (n = 200) working in selected units in acute care settings of three public hospitals in northern Jordan. Nurses' attitudes were described by using descriptive statistics. ANOVA and Pearson correlation were used to examine the effects of selected socio-demographic details and work characteristics on nurses' attitudes. Jordanian nurses who participated in this study had marginally positive attitudes toward older patients in acute care settings. Years of clinical experience correlated significantly with their attitudes. Male nurses had significantly more positive attitudes than their female counterparts. Surgical nurses also demonstrated significantly more positive attitudes than those working in medical units. Although positive attitudes emerged towards older people, it was also apparent that efforts should be made to enhance them further so that quality care is delivered to this population. In addition, Jordanian nurse educators should put a greater focus on issues related to the care of the older person in their nursing curriculum.

Developing an Outcome-based Multidisciplinary Care Planning Tool

Multidisciplinary care planning is required for patients in acute care settings. A task force was charged by the Vice President of Patient Care to develop and implement a multidisciplinary care planning tool. This article outlines the process used and includes examples of the tool and outcomes to date. This major change project resulted in the development of a successful tool, a successful Joint Commission on Accreditation of Healthcare Organization survey, and new opportunities for outcome-based care planning.

Assessing cardiovascular status: a guide for acute care nurses

Many patients admitted to acute care areas of a hospital experience cardiovascular compromise due to conditions such as acute myocardial infarction (AMI), acute coronary syndrome or exacerbations of chronic heart failure. Additionally, patients can experience cardiovascular collapse due to bleeding or cardiac arrhythmias postoperatively. As a consequence, nurses in acute care settings need to be competent in assessing the cardiovascular status of adult patients. The authors provide a framework for assessing the cardiovascular status of patients in acute care settings using the determinants of cardiac output. They provide a brief review of the determinants of cardiac output before discussing both the aims of cardiovascular assessment and how to perform, such an assessment. (non- author abstract)

The detection and treatment of posttraumatic distress and substance intoxication in the acute care inpatient setting

Each year, approximately 2.5 million Americans require inpatient admissions after sustaining traumatic physical injuries. Few investigations have assessed the routine detection and treatment of acute care inpatients with high levels of posttraumatic distress. A representative sample of 101 hospitalized patients with acute injuries was screened for posttraumatic stress disorder (PTSD) and depressive symptoms, as well as substance intoxication. Patients' medical records were reviewed for documentation of psychiatric symptoms and diagnoses and the initiation of early evaluation and treatment. High levels of PTSD and/or depressive symptoms were present in over 50% of patients. Although providers frequently noted symptomatic distress, few symptomatic patients received formal diagnoses, evaluations or treatment. Patients who had positive substance toxicology screens on admission infrequently received in-depth evaluation or treatment. A substantial number of injured trauma survivors have high levels of symptomatic distress that are inconsistently evaluated and treated in the acute care medical setting. Mental health interventions appear to be feasibly and effectively delivered from trauma centers. Therefore, ongoing investigation and policy initiatives informing the detection and treatment of patients with psychiatric disturbances in acute care could substantially enhance the quality of mental health care for injured survivors of individual and mass trauma.

Pharmacy cost evaluation of risperidone, olanzapine, and quetiapine for the treatment of schizophrenia in acute care inpatient settings

SUMMARYObjective: This study examines total pharmacy cost and usage patterns of schizophrenic patients in acute mental health inpatient settings for three atypical antipsychotics – risperidone, olanzapine, and quetiapine. Despite the readily available unit cost information for drugs, actual pharmacy costs may deviate significantly from ‘labeled costs’. Recent research findings indicate the need for more robust evaluation of such pharmacy costs.Research design and methods: This study used data from non-randomized inpatient retrospective charts from three acute care inpatient mental health facilities. The final pooled sample included 327 patients, of which 120 received risperidone, 153 received olanzapine, and 54 received quetiapine. Medication cost was defined as the average wholesale price (AWP) as listed in the 2001 ‘Red Book’. Propensity scoring methodology and multinomial regression were employed to reduce treatment selection bias.Results: The observed mean daily antipsychotic drug doses were 4.45 mg (SD 2.44) for risperidone, 14.04 mg (SD 5.55) for olanzapine, and 350.33 mg (SD 228.24) for quetiapine. The corresponding mean daily drug costs were $7.66(SD $4.20) for risperidone, $8.11 (SD $5.29) for quetiapine and, $12.10 (SD $4.79) for olanzepine. Numbers adjusted for treatment selection bias show that the average daily total pharmacy cost of risperidone was $4.35 lower than olanzapine ( p < 0.001) and $1.41 lower than quetiapine ( p = 0.38). The adjusted average daily pharmacy cost of olanzapine was $4.02 higher than quetiapine ( p < 0.001). After statistical adjustment there were no significant differences between study drugs in terms of length of stay or patient functioning.Conclusion: This study provides the first US comparison of medication utilization patterns and pharmacy costs for olanzapine, risperidone, and quetiapine administered in acute mental health care inpatient settings. While this study did not estimate the full economic value of the three antipsychotics in these inpatient settings, it demonstrated that the mean daily costs for risperidone were lower than the mean daily costs for olanzapine ( p < 0.001) and quetiapine although the later difference was not statistically significant ( p = 0.38).

A Knowledge Comparison of Nursing Students in Perioperative Versus Other Rotations

As more patients undergo surgical interventions in ambulatory facilities and patients in acute care settings have shorter lengths of stay, nursing students may have limited interaction with the surgical patient population. This study used a repeated measure, experimental design to compare knowledge of surgical patient care among undergraduate nursing students who experienced a perioperative clinical rotation (ie, experimental groups) with knowledge among students who experienced rotations in other clinical settings (ie, control groups). Results demonstrated a significant change in mean knowledge scores over time and a significant difference in mean scores between the experimental and control groups. Students in the perioperative group scored higher in all four testing periods.

Evaluation of an Electronic Monitoring Device for Urinary Incontinence in Elderly Patients in an Acute Care Setting

The primary aim of this study was to determine whether the use of habit training with an electronic monitoring device is better than standard habit training in the assessment and management of urinary incontinence in elderly patients in acute care hospitals. The second aim was to describe nurses' perceptions of continence management in acute care settings. A randomized controlled trial was conducted for an 18-month period. The sample consisted of 41 elderly incontinent patients who resided on the acute care rehabilitation wards of 2 western Australian hospitals. A continence assessment form was used to document self-reported or carer-reported frequency and severity of incontinence. A continence monitoring chart was used to record voiding patterns and continence outcomes. A semi-structured interview guide was developed to elicit nurses' perceptions of continence management. Findings revealed no significant improvements in the self-reported or carer-reported frequency of incontinence from baseline to follow-up of in-patients and at 1 month after discharge, although there was a trend toward improvement in both the experimental and the control groups at the posttest time points. A significant reduction in self-reported or carer-reported severity of incontinence was demonstrated in the experimental group at 1 month follow-up (P = 5.025).Nurses' perceptions of continence management of elderly patients in acute care settings ranged from positive to extremely negative. Even those with positive perceptions were challenged by problems with device malfunction, perceptions of lack of time, lack of support from other staff, and lack of knowledge about how best to meet the continence management needs of this complex group of patients. The potential value of an electronic monitoring device for reducing incontinence could not be adequately assessed because of the small sample size and problems with the device and with implementing the study protocol. Although it was possible to determine a pattern in voiding times using the electronic device, compliance with the toileting regimen was difficult to achieve.Researchers and clinicians planning future studies with this device should be aware of the practical limitations associated with habit-training regimens for elderly patients in the acute care setting.