Beth Quatrara

What Factors Are Associated With the Development of Pressure Ulcers in a Medical Intensive Care Unit

Statement of the Problem:Instruments used to determine the risk of pressure ulcer development are universally applied to adult patients. These instruments do not differentiate between intensive and acute care patients. Background:Pressure ulcers contribute to negative outcomes such as increases in pain and discomfort, risk of infection, hospital length of stay and costs, and a decrease in quality of life. Appropriately identifying risk factors is paramount to implementing a targeted care plan to avoid pressure ulcer development as well as pinpointing appropriate treatments if an ulcer develops. Objective:The purpose of this nursing research study was to identify factors associated with pressure ulcer development in a medical intensive care unit. Methods:A 15-month retrospective chart review of patients with pressure ulcers in a medical intensive care unit was performed. Statistics were computed on demographics and variables of interest including: pressure ulcer stage, vasopressor infusion, oxygen requirement, comorbidities, primary diagnosis, length of stay, mortality, age, gender, weight, Braden scores, and albumin level. Results:The characteristics of 76 patients who developed pressure ulcers were evaluated. An equal number of men (n = 38) and women (n = 38) were included. Forty-seven percent had a stage II pressure ulcer. The presence of hemodynamic support with vasopressor administration (P = .016) and the length of stay (P = .021) were noted as the most significant factors in pressure ulcer development in this study. Conclusions:Vasopressor use and length of stay are not factors that are accounted for in current pressure ulcer risk assessment instruments. The administration of vasopressor support and patient length of stay are potential contributory factors that need to be considered when assessing patients. Instruments specific to intensive care unit pressure ulcer risk stratification are warranted and should include the unique characteristics of a critically ill patient.

APN-led nursing rounds: An emphasis on evidence-based nursing care

In todays healthcare environment, nursing staff are challenged to care for patients with increasingly complex needs in an ever-changing environment. Nurses are expected to stay up to date on a tremendous number of institutional initiatives, best practice guidelines, and policies and procedures. These practice imperatives are often disseminated through passive means of information-sharing such as staff meetings and electronic mail. In this setting, it is difficult for nurses to simultaneously focus on incorporating practice updates while continuing to value basic nursing functions such as oral care, skin care, and incontinence management. The concept of Interventional Patient Hygiene emphasises that basic nursing functions are not only tasks, but also important evidence-based interventions that contribute to improved health for the patient. Interventional Patient Hygiene facilitates the integration of science and practice. This article describes a quality improvement intervention, Advanced practice nurse-led nursing rounds, which supports Interventional Patient Hygiene and be used to help staff integrate best practices while balancing the multiple priorities inherent in nursing care.

What is the Least Painful Method of Anesthetizing a Peripheral IV Site

The placement of an intravenous (IV) catheter for the administration of fluids, blood products, and medications is a common intervention for surgical procedures and perianesthesia patients. Although the placement of a peripheral IV may be routine for perianesthesia nurses, it is important to address the patients level of pain related to the procedure. One technique to diminish the discomfort associated with the IV insertion is anesthetizing the site. The purpose of this study was to compare three methods for anesthetizing peripheral IV catheter sites before insertion to determine which method provides optimal patient comfort during the anesthetizing and IV catheter insertion process. The findings demonstrate that there was no statistical difference in pain when anesthetizing the site using the three methods. However, there was a difference with the IV insertion process. Using 1% lidocaine resulted in the least painful IV insertion.

Does Site Matter? Comparing Accuracy and Patient Comfort of Blood Glucose Samples Taken From the Finger and Palm of the Perioperative Patient

Purpose: This study compared two blood glucose (BG) point of care sampling methods to determine which is least painful yet accurate. Design: The two‐period, two‐treatment crossover trial compared the traditional fingertip sampling method to a form of alternative site testing (AST), palm of the hand. Methods: Subjects received both methods of BG sampling to compare comfort and accuracy. They were randomly assigned to determine which method was used first. Pain rating (0 to 10) and glucose results for both methods were documented. Finding: Results indicated that pain rating was significantly lower with AST (1.65) than with the standard site (2.83) (P < .001). There was no significant difference in mean glucose measurements between standard care (150 mg/dL) and AST (149 mg/dL). The numbers were closely correlated (r = 0.9815). Conclusions: Findings support AST via the palm of the hand as an accurate and less painful method of obtaining BG results on diabetic patients.

Incongruence in Perceptions: Identifying Barriers to Patient Satisfaction in the Intensive Care Unit

Background: Patient satisfaction is at the forefront of quality care and patient outcomes. The literature identifies the discrepancy between nurse and patient perceptions in a variety of care settings; few studies have investigated the perceptions of care in a critical care unit. Understanding the perceptions in a critical care unit is necessary to optimize organizational performance related to quality, safety, patient-centered care, and efficiency. Objective: The purpose of the study was to determine whether a discrepancy exists between what patients and families perceive as satisfaction with their care as compared with the nurses’ perception of what constitutes positive patient satisfaction in a medical critical care unit. Methods: A cross-sectional, prospective study was conducted to assess patient-perceived satisfaction with nursing care versus nursing perceptions in the medical intensive care unit. A convenience sample of patients and/or family members and the nurses providing their care was conducted. The validated Patient Satisfaction with Nursing Care Quality Questionnaire and Nurse’s Assessment of the Patient’s Expectations Questionnaire were used to assess perceptions. Patients and/or their family members and nurses’ responses were evaluated as matched pairs. The data were analyzed using Spearman correlation. Results: Forty-eight matched pairs of questionnaires were completed. There was not a correlation (r = 0.135; 95% confidence interval, −0.16 to 0.41; P = .363) between the overall patient and nurse averages for common questions. The analysis of the individual patient and nurse items revealed statistically significant correlations between only 2 of the 19 items, information given (P = .027) and recognition of opinions (P = .043). Correlations within patient questionnaires were noted in some areas such as patients’ perception of quality of care and expectations, overall quality of nursing care, and patient expectations and patients’ likelihood to recommend the hospital to family and friends. Patient satisfaction was influenced by a number of factors, most notably patient expectations. Implications for Practice: Nurses’ perceptions of positive patient satisfaction in critical care are incongruent with patients’ perceptions. Improving nurses’ awareness of the patient experience could improve patient satisfaction. Further studies examining patient expectations could be beneficial in improving patient satisfaction in the critical care setting.

Cleanliness of Disposable vs Nondisposable Electrocardiography Lead Wires in Children

BACKGROUND Mediastinitis costs hospitals thousands of dollars a year and increases the incidence of patient morbidity and mortality. No studies have been done to evaluate adenosine triphosphate (ATP) counts on disposable and nondisposable electrocardiography (ECG) lead wires in pediatric patients. OBJECTIVE To compare the cleanliness of disposable and nondisposable ECG lead wires in postoperative pediatric cardiac surgery patients by measuring the quantity of ATP (in relative luminescence units [RLUs]). ATP levels correlate with microbial cell counts and are used by institutions to assess hospital equipment and cleanliness. METHODS A prospective, randomized trial was initiated with approval from the institutional review board. Verbal consent was obtained from the parents/guardians for each patient. Trained nurses performed ATP swabs on the right and left upper ECG cables on postoperative days 1, 2, and 3. RESULTS This study enrolled 51 patients. The disposable ECG lead wire ATP count on postoperative day 1 (median, 157 RLUs) was significantly lower (P < .001) than the count for nondisposable ATP lead wires (median, 610 RLUs). On postoperative day 2, the ATP count for the disposable ECG lead wires (median, 200 RLUs) was also lower (P = .06) than the count for the nondisposable ECG lead wires (median, 453 RLUs). CONCLUSION Results of this study support the use of disposable ECG lead wires in postoperative pediatric cardiac surgery patients for at least the first 48 hours as a direct strategy to reduce the ATP counts on ECG lead wires.

Blood conservation: what is current blood draw practice?

The new AABB guidelines for red blood cell transfusions narrow the threshold for transfusion. A natural outgrowth is to emphasize blood conservation strategies, including reduced blood draws. There is no universal practice for the collection of blood or strategy for blood conservation. As such, it is often assumed that frequency and amounts of blood drawn vary with patient acuity, caregiver experience, and patient length of stay. Yet, a descriptive study did not identify any significant differences in these variables. Creating a culture of low-volume blood drawing may help to reduce blood transfusions.

A Pilot Study: Comparison of Arm Versus Ankle Noninvasive Blood Pressure Measurement at 2 Different Levels of Backrest Elevation.

Background:Standard practice for obtaining noninvasive blood pressure includes arm blood pressure (BP) cuff placement at the level of the heart; however, some critical care patients cannot have BPs taken in their arm because of various conditions, and ankle BPs are frequently used as substitutes. Objective:The aim of this study was to determine if there was a significant variation between upper arm and ankle BP measurements at different backrest elevations with consideration of peripheral edema factors. Methodology:After institutional review board approval was obtained, a pilot study was implemented to evaluate noninvasive BP measurements of the arm and ankle with backrest elevation at 0° and 30° in a population of medical intensive care unit patients. Participants served as their own controls and were randomly assigned to left- versus right-side BP readings. Data were also collected on presence of arm versus ankle edema. Results:A total of 30 participants enrolled in the study and provided 120 BP measurements. Blood pressure readings were analyzed in terms of diastolic and systolic findings as well as backrest elevations and edema presence. Thirteen participants presented with either arm or ankle edema. There was a statistical difference between the systolic arm and ankle BP measurements in the 0° (P = .008) and 30° (P < .001) backrest elevation positions. The correlation between arm and ankle diastolic BP is greater for participants without ankle edema (P = .038, r = 0.54) than for participants with ankle edema (P = .650, r = 0.14), but it is not statistically significant (P = .47). Discussion:Even though ankle BPs are often substituted for arm BPs when the arm is unable to be used, ankle BPs and arm BPs are not interchangeable. Adjustments in backrest elevation and considerations of edema do not normalize the differences. Blood pressures obtained from the ankle are significantly greater than those obtained from the arm. This information needs to be considered when arms are not available and legs are used as surrogates for the upper arm.

852Housewide use of Chlorehexidine Bathing to reduce Healthcare Associated Infections

Associated Infections Kyle Enfield, MD, MS; Costi D. Sifri, MD; Elizabeth Enfield, RN, MSN; Jessica Lewis, MD; Beth Quatrara, DNP, RN, CMSRN, ACNS-BC; Eve Giannetta, RN, BSN, CIC; Kristi Kimpel, RN, MSN; Kathleen Rea, RN, MSN; Department of Medicine, Division of Pulmonology, Hospital Epidemiology/Infection Prevention and Control, University of Virginia Health System, Charlottesville, VA; Department of Medicine, Division of Infectious Diseases and International Health, Hospital Epidemiology/Infection Prevention and Control, University of Virginia Health System, Charlottesville, VA; Coronary Care Unit, University of Virginia, Charlottesville, VA; Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville, VA; University of Virginia, Charlottesville, VA; Infection Prevention and Control, University of Virginia Health System, Charlottesville, VA; Surgical Trauma Burn ICU, University of Virginia, Charlottesville, VA; Surgical Services/5 Central, University of Virginia, Charlottesville, VA