Daleen Penoyer

Assessment of Endotracheal Cuff Pressure by Continuous Monitoring: A Pilot Study

BACKGROUND Endotracheal tube cuff pressure must be maintained within a narrow therapeutic range to prevent complications. Cuff pressure is measured and adjusted intermittently. OBJECTIVES To assess the accuracy and feasibility of continuous monitoring of cuff pressure, describe changes in cuff pressure over time, and identify clinical factors that influence cuff pressure. METHODS In a pilot study, data were collected for a mean of 9.3 hours on 10 patients who were orally intubated and receiving mechanical ventilation. Sixty percent of the patients were white, mean age was 55 years, and mean intubation time was 2.8 days. The initial cuff pressure was adjusted to a minimum of 20 cm H2O. The pilot balloon of the endotracheal tube was connected to a transducer and a pressure monitor. Cuff pressure was recorded every 0.008 seconds during a typical 12-hour shift and was reduced to 1-minute means. Patient care activities and interventions were recorded on a personal digital assistant. RESULTS Values obtained with the cufflator-manometer and the transducer were congruent. Only 54% of cuff pressure measurements were within the recommended range of 20 to 30 cm H2O. The cuff pressure was high in 16% of measurements and low in 30%. No statistically significant changes over time were noted. Endotracheal suctioning, coughing, and positioning affected cuff pressure. CONCLUSIONS Continuous monitoring of cuff pressure is feasible, accurate, and safe. Cuff pressures vary widely among patients.

Oropharyngeal Secretion Volume in Intubated Patients: The Importance of Oral Suctioning

BACKGROUND Aspiration of secretions that accumulate above the cuff of the endotracheal tube is a risk factor for ventilator-associated pneumonia. Routine suctioning of oropharyngeal secretions may reduce this risk; the recommended frequency for suctioning is unknown. OBJECTIVES To quantify the volume of secretions suctioned from the oropharynx of critically ill patients at 2 different intervals to assist in identifying a recommended frequency for oropharyngeal suctioning. METHODS A prospective, repeated measure, single-group design was used. Twenty-eight patients who were orally intubated and treated with mechanical ventilation were enrolled; 2 were extubated during data collection, yielding a sample of 26 patients. The patients were suctioned at baseline with a deep suction catheter, and the volume and weight of secretions were recorded. The procedure was repeated at 2-hour and 4-hour intervals. RESULTS Most of the patients were male (mean age, 49 years). Three suctioning passes were needed to clear secretions, with a mean time of 48.1 seconds. The mean volume of secretions at the 2-hour interval was 7.5 mL. Five patients required suctioning before the 4-hour interval. For the remaining 21 patients, the volume retrieved was 6.5 mL at the 2-hour interval and 7.5 mL at the 4-hour interval (P = .27). The 5 patients who required extra suctioning had significantly more secretions at the 2-hour interval (11.6 mL vs 6.5 mL; P = .05). CONCLUSIONS A minimum frequency of oropharyngeal suctioning every 4 hours is recommended. However, more frequent suctioning may be needed in a subset of patients.

Use of electronic health record documentation by healthcare workers in an acute care hospital system.

EXECUTIVE SUMMARY Acute care clinicians spend significant time documenting patient care information in electronic health records (EHRs). The documentation is required for many reasons, the most important being to ensure continuity of care. This study examined what information is used by clinicians, how this information is used for patient care, and the amount of time clinicians perceive they review and document information in the EHR. A survey administered at a large, multisite healthcare system was used to gather this information. Findings show that diagnostic results and physician documents are viewed more often than documentation by nurses and ancillary caregivers. Most clinicians use the information in the EHR to understand the patients overall condition, make clinical decisions, and communicate with other caregivers. The majority of respondents reported they spend 1 to 2 hours per day reviewing information and 2 to 4 hours documenting in the EHR. Bedside nurses spend 4 hours per day documenting, with much of this time spent completing detailed forms seldom viewed by others. Various flow sheets and forms within the EHR are rarely viewed. Organizations should provide ongoing education and awareness training for hospital clinical staff on available forms and best practices for effective and efficient documentation. New forms and input fields should be added sparingly and in collaboration with informatics staff and clinical team members to determine the most useful information when developing documentation systems.

Clinical nurse specialist assessment of nurses' knowledge of heart failure.

Purpose/Objective: Patients’ self-management of heart failure (HF) is associated with improved adherence and reduced readmissions. Nurses’ knowledge about self-management of HF may influence their ability to adequately perform discharge education. Inadequate nurse knowledge may lead to insufficient patient education, and insufficient education may decrease patients’ ability to perform self-management. Prior to developing interventions to improve patient education, clinical nurse specialists should assess nurses’ knowledge of HF. The purpose of this study was to determine nurses’ knowledge of HF self-management principles. Design: This was a prospective, exploratory, and descriptive online test. Settings: There were 3 patient care settings: tertiary care teaching hospital, community hospital, and home healthcare division. Sample: The sample was composed of 90 registered nurses who worked directly with patients with HF. Methods: Nurses completed an online test of knowledge using the Nurses’ Knowledge of Heart Failure Education Principles instrument. Findings: Registered nurses (n = 90) completed the knowledge test instrument; their average score was 71% (SD, 10.8%) (range, 20%–90%). The percentage of correct items on each subscale ranged from 63.9% (SD, 30.0) for medications to 83.3% (SD, 25.0) for exercise. Only 8.9% of respondents achieved a passing score of greater than 85%, and a passing score was not associated with any demographic characteristics. Conclusions: Overall, nursing knowledge of HF self-management principles was low. Scores from our nurses were similar to those found in other studies. Implications: There is a need to develop interventions to improve nursing knowledge of HF self-management principles. Clinical nurse specialists can be instrumental in developing knowledge interventions for nurses.

Timing is everything: results to an observational study of mealtime insulin practices.

Purpose: The purpose of this study was to evaluate the timing and practices of blood glucose testing and rapid-acting insulin administration around mealtimes. Design: This study used an observational, descriptive design to assess the time between blood glucose testing and insulin administration and the time between first bite of the meal and insulin administration. Setting: The setting was 4 cardiology units in 2 hospitals within a large community healthcare system. Sample: Sixty-four mealtime practice events at breakfast, lunch, and supper were observed. Methods: Investigators directly observed the timing of rapid-acting insulin administration at 3 mealtime periods an assessed timing of blood glucose testing, food intake, and method of glucose reporting. Results: Overall, 14% (n = 64) of the patients received blood glucose testing within 1 hour prior to insulin administration and insulin administration within 15 minutes of the meal. As separate elements, blood glucose testing was done within the defined ideal range 35% (n = 63) of the time, and insulin was administered within range 40% (n = 58) of the time. Conclusions: Timing for meals, blood glucose testing, and rapid-acting insulin administration varied significantly and was not well synchronized among the various patient caregivers with low achievement of ideal practices. Implications: Results to this study revealed opportunities for better coordination of mealtime insulin practices. Lack of coordination can lead to medication errors and adverse drug events. Further study should include effect of mealtime coordination on glycemic control outcomes and testing the effect of interventions on timing of mealtime insulin practices.

Two Hours of Teamwork Training Improves Teamwork in Simulated Cardiopulmonary Arrest Events.

Purpose/Aim: Teamwork during cardiopulmonary arrest events is important for resuscitation. Teamwork improvement programs are usually lengthy. This study assessed the effectiveness of a 2-hour teamwork training program. Design: A prospective, pretest/posttest, quasi-experimental design assessed the teamwork training program targeted to resident physicians, nurses, and respiratory therapists. Methods: Participants took part in a simulated cardiac arrest. After the simulation, participants and trained observers assessed perceptions of teamwork using the Team Emergency Assessment Measure (TEAM) tool (ratings of 0 [low] to 4 [high]). A debriefing and 45 minutes of teamwork education followed. Participants then took part in a second simulated cardiac arrest scenario. Afterward, participants and observers assessed teamwork. Results: Seventy-three team members participated—resident physicians (25%), registered nurses (32%), and respiratory therapists (41%). The physicians had significantly less experience on code teams (P < .001). Baseline teamwork scores were 2.57 to 2.72. Participants’ mean (SD) scores on the TEAM tool for the first and second simulations were 3.2 (0.5) and 3.7 (0.4), respectively (P < .001). Observers’ mean (SD) TEAM scores for the first and second simulations were 3.0 (0.5) and 3.7 (0.3), respectively (P < .001). Program evaluations by participants were positive. Conclusions: A 2-hour simulation-based teamwork educational intervention resulted in improved perceptions of teamwork behaviors. Participants reported interactions with other disciplines, teamwork behavior education, and debriefing sessions were beneficial for enhancing the program.

Comparison of Respiratory Infections before and after Percutaneous Tracheostomy

BACKGROUND A tracheostomy is often performed when patients cannot be weaned from mechanical ventilation. Respiratory infections (ventilator-associated pneumonia and infection of the lower respiratory tract) complicate the course of hospitalization in patients receiving mechanical ventilation. OBJECTIVES To evaluate respiratory infections before and after a percutaneous tracheostomy and to describe their outcomes. METHODS Medical records of adults who had percutaneous tracheostomy during a 1-year period at a tertiary care hospital in the southeastern United States were reviewed retrospectively. RESULTS Data for 322 patients were analyzed. Patients were predominately male (63.0%) and white (57.8%), with a mean age of 57.4 years. Ventilator-associated pneumonia or infection of the lower respiratory tract was identified in 90 patients (28.0%); the majority of infections were lower respiratory infections. Of all infections, 52% occurred before the tracheostomy, and 48% occurred after the procedure. Respiratory infections were associated with longer stays and higher costs, which were significantly higher in patients in whom the infection developed after the tracheostomy. Gram-negative organisms were responsible for the majority of infections. CONCLUSIONS Data related to respiratory infections that occurred before a tracheostomy were similar to data related to infections that occurred after a tracheostomy. Most infections were classified as lower respiratory infection rather than pneumonia. Infection, before or after a tracheostomy, resulted in longer stays and higher costs for care. Interventions focused on preventing infection before and after tracheostomy are warranted.

Perceptions of teamwork among code team members.

Background: Cardiopulmonary arrest (CPA) teams, known as code teams, provide coordinated and evidenced-based interventions by various disciplines during a CPA. Teamwork behaviors are essential during CPA resuscitation and may have an impact on patient outcomes. Objectives: The purpose of this study was to explore the perceptions of teamwork during CPA events among code team members and to determine if differences in perception existed between disciplines within the code team. Methods: A prospective, descriptive, comparative design using the Code Teamwork Perception Tool online survey was used to assess the perception of teamwork during CPA events by medical residents, critical care nurses, and respiratory therapists. Results: Sixty-six code team members completed the Code Teamwork Perception Tool. Mean teamwork scores were 2.63 on a 5-point scale (0–4). No significant differences were found in mean scores among disciplines. Significant differences among scores were found on 7 items related to code leadership, roles and responsibilities between disciplines, and in those who had participated on a code team for less than 2 years and certified in Advanced Cardiac Life Support for less than 4 years. Conclusions: Teamwork perception among members of the code team was average. Teamwork training for resuscitation with all disciplines on the code team may promote more effective teamwork during actual CPA events. Clinical nurse specialists can aid in resuscitation efforts by actively participating on committees, identifying opportunities for improvement, being content experts, leading the development of team training programs, and conducting research in areas lacking evidence.

Collecting Nursing Research Data 24 Hours a Day: Challenges, Lessons, and Recommendations

Background Research on many routine nursing interventions requires data collection around the clock each day (24/7). Strategies for implementing and coordinating a study 24/7 are not discussed in the literature, and best practices are needed. Objective To identify strategies incorporated into implementing a nursing intervention trial 24/7, including key lessons learned. Methods Strategies to facilitate implementation of a clinical trial of a nursing intervention with patients undergoing mechanical ventilation are shared. Challenges and changes for future studies also are discussed. Results Adequate planning, including a detailed operations manual, guides study implementation. Staffing is the most challenging and costly part of a study but is essential to a study’s success. Other important strategies include communication among the study personnel and with collaborators and direct care staff. An electronic method of recording study‐related data also is essential. Conclusions A nursing clinical trial that requires interventions on a 24/7 basis can be done with thorough planning, staffing, and continuous quality improvement activities.

Assessment of Mesenteric Tissue Saturation, Oxygen Saturation, and Heart Rate Pre- and Post-Blood Transfusion in Very Low-Birth-Weight Infants Using Abdominal Site Near-Infrared Spectroscopy

BACKGROUND Preterm infants often receive blood transfusions during hospitalization. Although transfusions are intended to enhance oxygen delivery, previous studies found decreases in tissue and mesenteric oxygen saturation during and after blood transfusions without changes in vital signs and hemoglobin oxygen saturation. PURPOSE To study the effect of blood transfusions on regional mesenteric tissue oxygen saturation (rSO2), hemoglobin saturation of oxygen (SpO2), and heart rate (HR) in premature infants. METHOD A prospective, observational, nonrandomized study using a repeated-measures design was done to evaluate changes in physiologic variables (HR, SpO2, rSO2) before, during, and after a blood transfusion in premature infants. RESULTS A convenience sample of 30 infants with a mean gestational age of 25.5 (2.1) weeks was recruited. Repeated-measures analysis of variance found no significant differences in HR (P = .06) and SpO2 (P = .55) over time. However, significant differences occurred in rSO2 over the 3 time periods (P < .001). The rSO2 increased during the transfusion from 40.3% to 41.5%, but decreased to 34.9% in the posttransfusion period. Pairwise comparisons revealed statistically significant mean rSO2 differences between pretransfusion and posttransfusion (P < .001), and during transfusion to posttransfusion (P < .001) periods. IMPLICATIONS FOR RESEARCH This study supports previous findings of perfusion changes during blood transfusions in preterm infants. IMPLICATIONS FOR PRACTICE Measuring mesenteric tissue oxygenation during blood transfusion in very low-birth-weight infants can potentially add another physiologic parameter to guide further clinical assessment and interventions during transfusions.Background: Preterm infants often receive blood transfusions during hospitalization. Although transfusions are intended to enhance oxygen delivery, previous studies found decreases in tissue and mesenteric oxygen saturation during and after blood transfusions without changes in vital signs and hemoglobin oxygen saturation. Purpose: To study the effect of blood transfusions on regional mesenteric tissue oxygen saturation (rSO2), hemoglobin saturation of oxygen (SpO2), and heart rate (HR) in premature infants. Method: A prospective, observational, nonrandomized study using a repeated-measures design was done to evaluate changes in physiologic variables (HR, SpO2, rSO2) before, during, and after a blood transfusion in premature infants. Results: A convenience sample of 30 infants with a mean gestational age of 25.5 (2.1) weeks was recruited. Repeated-measures analysis of variance found no significant differences in HR (P = .06) and SpO2 (P = .55) over time. However, significant differences occurred in rSO2 over the 3 time periods (P < .001). The rSO2 increased during the transfusion from 40.3% to 41.5%, but decreased to 34.9% in the posttransfusion period. Pairwise comparisons revealed statistically significant mean rSO2 differences between pretransfusion and posttransfusion (P < .001), and during transfusion to posttransfusion (P < .001) periods. Implications for Research: This study supports previous findings of perfusion changes during blood transfusions in preterm infants. Implications for Practice: Measuring mesenteric tissue oxygenation during blood transfusion in very low-birth-weight infants can potentially add another physiologic parameter to guide further clinical assessment and interventions during transfusions.