Cheryl Newton

Predictive Validity of the Braden Scale for Patients in Intensive Care Units

BACKGROUND Patients in intensive care units are at higher risk for development of pressure ulcers than other patients. In order to prevent pressure ulcers from developing in intensive care patients, risk for development of pressure ulcers must be assessed accurately. OBJECTIVES To evaluate the predictive validity of the Braden scale for assessing risk for development of pressure ulcers in intensive care patients by using 4 years of data from electronic health records. Methods Data from the electronic health records of patients admitted to intensive care units between January 1, 2007, and December 31, 2010, were extracted from the data warehouse of an academic medical center. Predictive validity was measured by using sensitivity, specificity, positive predictive value, and negative predictive value. The receiver operating characteristic curve was generated, and the area under the curve was reported. RESULTS A total of 7790 intensive care patients were included in the analysis. A cutoff score of 16 on the Braden scale had a sensitivity of 0.954, specificity of 0.207, positive predictive value of 0.114, and negative predictive value of 0.977. The area under the curve was 0.672 (95% CI, 0.663-0.683). The optimal cutoff for intensive care patients, determined from the receiver operating characteristic curve, was 13. CONCLUSIONS The Braden scale shows insufficient predictive validity and poor accuracy in discriminating intensive care patients at risk of pressure ulcers developing. The Braden scale may not sufficiently reflect characteristics of intensive care patients. Further research is needed to determine which possibly predictive factors are specific to intensive care units in order to increase the usefulness of the Braden scale for predicting pressure ulcers in intensive care patients.

Swallowing assessment in primary brain tumor patients with dysphagia

Dysphagia is a common problem in patients with neurologic disease and is often associated with significant morbidity and mortality. To evaluate primary brain tumor patients who complained of dysphagia, we adapted grading scales for severity of complaint and level of alertness (scale of 1 to 4) and bedside swallowing assessment and videofluoroscopic examination (scales of 1 to 5). Over 13 months, we prospectively screened 117 patients for dysphagia. Seventeen of these (14.5%) complained of dysphagia (mean age, 50.2 years; range, 20 to 75); an additional six control patients were studied from a group with no dysphagic complaints. Scoring for severity of complaint (mean, 2.3) and level of alertness (mean, 2.2) was mild-moderate in the majority of patients. Eleven of 17 patients scored ≥ grade 3 (mean 3.2, moderate impairment, requiring supervision) on bedside testing, and six of seven scored ≥ grade 3 (mean 3.8, moderate-moderately severe abnormality, trace or frequent aspiration) during videofluoroscopic evaluation. Bedside testing scores of the study group differed significantly (p < 0.001) from those of the control group. Level of alertness correlated strongly with bedside (r = 0.794) and videofluoroscopic (r = 0.780) scoring. Primary brain tumor patients with dysphagia are likely to have impairment of swallowing out of proportion to their complaints and therefore are at risk for aspiration and nutritional compromise. We recommend that these patients undergo formal swallowing assessment followed by rehabilitation or implementation of alternative feeding methods.

Attempted dose intensified cyclophosphamide, etoposide, and granulocyte colony-stimulating factor for treatment of malignant astrocytoma

SummaryPatients with malignant astrocytoma continue to respond poorly to chemotherapy and have a dismal prognosis. Cyclophosphamide (CTX) and etoposide demonstrate activity against malignant astrocytoma at standard dosages, with bone marrow suppression as the limiting toxicity. In order to allow dose intensification, minimize leukopenia, and improve efficacy granulocyte colony-stimulating factor (G-CSF) was used in combination with CTX and etoposide. The protocol consisted of CTX (2 mg/m2/d, days 1, 2), etoposide (200–300 mg/m2/d, days 1–3), and G-CSF (5–10 μg/d subcutaneously, days 4–18), every 4 weeks. Nine evaluable patients (7 glioblastoma multiforme, 2 anaplastic astrocytoma) were treated, ranging in age from 26–67 (mean 41). One of 9 patients responded (11%) with a partial response (13+ months), 3 had stable disease (33%; 8, 5, 2.5 months), and 5 had progressive disease (3, 2.5, 2, 1.5, 1 months). The median time to progression for responders was 6.5 months, while overall it was 2.5 months. Overall median survival was only 7.0 months. Toxicity was frequent and severe, typically delaying treatment cycles. The most common complications were severe myeolosuppression (9), sepsis (8), rash (6), urinary infection (5), and anorexia (5). Treatment delays caused by infections and other complications occurred often, abrogating the intended dose intensification. The received dose intensity (DI) for CTX was 400–425 mg/m2/week (relative DI 0.41), while for etoposide it was 75 mg/m2/ week (relative DI 0.42). In summary, as used in this protocol, dose intensive chemotherapy with CTX, etoposide, and G-CSF does not improve efficacy over standard regimens and results in excessive toxicity.

Outcomes of an Oral Care Protocol in Postmechanically Ventilated Patients

BACKGROUND Oral care is standard practice to prevent hospital-associated infections while patients are intubated and in the intensive care unit. Following extubation and transfer, infections remain an important risk for patients, but less attention is paid to oral care. Few studies have assessed the impact of oral care in recently extubated acutely ill patients. AIMS To develop an evidence-based oral care protocol for hospitalized patients and determine the impact of this protocol on health outcomes in recently extubated patients. METHODS In this randomized controlled trial, subjects were randomized to usual care or an intervention protocol that included tooth brushing, tongue scraping, flossing, mouth rinsing, and lip care. Major outcome measures were the revised THROAT (R-THROAT; oral cavity assessment) and overall prevalence of methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus on oral cultures. RESULTS Seventy-four subjects were randomized. As measured by the R-THROAT, oral cavity health improved over time in both groups, but the intervention group demonstrated significantly more improvement than the control group (R-THROAT score improved by 1.97 intervention vs. 0.87 control; p = .04). Two categories, tongue and mouth comfort, demonstrated the most significant improvement. There was no difference in MSSA/MRSA colonization between the groups at the conclusion of the study. Overall, subjects in the intervention group were more satisfied with their protocol than subjects in the usual care group. LINKING EVIDENCE TO ACTION This study offers an important evaluation of an oral care protocol after extubation. Results demonstrated improvement in the oral cavity assessment with the designed oral care protocol. Patients expressed a preference for the intervention protocol, which included a battery-operated toothbrush, higher-quality toothpaste and mouth rinse, tongue scraper, floss, and lip balm. The implementation of an oral care protocol specifically addressing patients in the immediate postintubation is essential.

Nurses' Attitudes Regarding the Safe Handling of Patients Who Are Morbidly Obese: Instrument Development and Psychometric Analysis

Background and Purpose: Nurses’ attitudes play an important role in the consistent practice of safe patient handling behaviors. The purposes of this study were to develop and assess the psychometric properties of a newly developed instrument measuring attitudes of nurses related to the care and safe handling of patients who are obese. Methods: Phases of instrument development included (a) item generation, (b) content validity assessment, (c) reliability assessment, (d) cognitive interviewing, and (e) construct validity assessment through factor analysis. Results: The final data from the exploratory factor analysis produced a 26-item multidimensional instrument that contains 9 subscales. Conclusions: Based on the factor analysis, a 26-item instrument can be used to examine nurses’ attitudes regarding patients who are morbidly obese and related safe handling practices.

Stamping out hypoglycemia in a surgical Intensive Care Unit: A multidisciplinary approach

Context: Both hyperglycemia and hypoglycemia can significantly impact outcomes in critically ill patients. In the Intensive Care Unit (ICU), hypoglycemia is often the result of intensive insulin therapy. Aims: The purpose of this study is to assess the impact of insulin infusion associated hypoglycemia using a multidisciplinary quality improvement approach with targeted education and real-time follow-up in a surgical ICU. Setting and Design: A concurrent study in a surgical ICU of an academic medical center. Materials and Methods: Our clinical pharmacists concurrently reviewed all cases of hypoglycemia (glucose <74 mg/dL) from March 16, 2010, to March 15, 2011. For cases of hypoglycemia judged related to insulin infusions, the pharmacists and unit clinical nurse specialists reviewed each case for compliance with institutional guidelines, and unit clinical nurse specialists or nurse managers provided targeted education to the bedside nurses involved. In August 2010, we performed unit wide nursing education on glycemic control and the insulin infusion guideline. Causes of hypoglycemic events were compared before and after education was completed. Statistical Analysis: Fishers exact test for nominal data. Results: Four hundred and twenty-nine hypoglycemic events (188 patients) occurred in 2233 patient admissions. Most events involved administration of insulin (40%), including 106 (25%) involving insulin infusions and 59 (14%) associated with sliding scale insulin administration. Education significantly reduced the percentage of hypoglycemic events due to noncompliance (47% pre vs. 17% post, P = 0.002). Conclusions: Education and unit feedback with concurrent staff follow-up were associated with a significant reduction in the rate of hypoglycemic events. The following core competencies are addressed in this article: Patient care, practice-based learning and improvement.