Denise O'Brien

ASPAN's Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia

Practice Guideline for the Promotion of Perioperative Normothermia Vallire D. Hooper, PhD, RN, CPAN, FAAN, Robin Chard, PhD, RN, CNOR, Theresa Clifford, MSN, RN, CPAN, Susan Fetzer, PhD, RN, Susan Fossum, BSN, RN, CPAN, Barbara Godden, MHS, RN, CPAN, CAPA, Elizabeth A. Martinez, MD, MHS, Kim A. Noble, PhD, RN, CPAN, Denise O’Brien, MSN, RN, ACNS-BC, CPAN, CAPA, FAAN, Jan Odom-Forren, PhD, RN, CPAN, FAAN, Corey Peterson, MSN, CRNA, Jacqueline Ross, MSN, RN, CPAN

Intraoperative Risk Factors Associated With Postoperative Pressure Ulcers in Critically Ill Patients: A Retrospective Observational Study*

Objective:The risk for pressure ulcers is rarely identified in the perioperative period, and the influence of this period on risk factors has not been as rigorously studied as the postoperative period. We hypothesized that intraoperative risk factors exist, which increase the likelihood of a postoperative new-onset pressure ulcer. Design:A retrospective observational study. Setting:A large midwestern U.S. quaternary care institution. Patients:A total of 2,695 adult surgical patients underwent operative procedures and received care in one of three ICUs using an electronic documentation application. Interventions:None. Measurements and Main Results:The primary outcome was hospital-acquired pressure ulcer categorized as stages II, III, and IV; deep tissue injury; or unstageable. Univariate analyses comparing patients with and without the outcome of pressure ulcers were conducted for each preoperative characteristic or comorbidity. Patients were matched using the logit of the propensity score based solely on their preoperative comorbidities. Adjusted associations between development of pressure ulcers and intraoperative characteristics were determined in the postmatch cohort. We identified seven independent preoperative patients’ characteristics and comorbidities in our adult surgical patient sample: American Society of Anesthesiologists risk classification 4 or 5, underweight body mass index, noncardiac surgery, history of congestive heart failure, renal disease, existing airway present prior to arrival in the operating room, and age. The only significant association in the matched dataset accounting for patient preoperative variability is the use of intraoperative blood products. Conclusion:Postoperative pressure ulcers developed in 10.7% of critically ill patients in our study. Only intraoperative use of blood products, not operative case length, hypotension, or vasopressor use, was associated with postoperative pressure ulcer development on adjusted analysis.

Comfort, satisfaction, and anxiolysis in surgical patients using a patient-adjustable comfort warming system: a prospective randomized clinical trial.

Comfort warming systems aim to produce a comfortable local environment over which the individual patient has control. We studied a patient-adjustable comfort warming system using the Bair PAWS (Patient Adjustable Warming System) (Arizant Healthcare, Inc, Eden Prairie, MN), specifically to study comfort warming rather than therapeutic warming. One-hundred thirty patients were enrolled in this prospective randomized clinical trial, with 58 patients randomized to the patient warming gown, and 72 randomized to the warm blanket group. Groups were similar for gender, age, height, weight, surgical time, body surface area, and body mass index. The patient-adjustable warming system group had perceived greater control and satisfaction at 30 minutes after treatment was initiated compared with the warmed blanket control group. However, there were no differences in satisfaction levels with thermal comfort among those patients contacted one day postoperatively. Additional research is needed to improve external validity of study findings. Further refinement of a nursing definition of thermal comfort should be explored.

Prone positioning: is it safe and effective?

Prone positioning has been used as a treatment option for patients with acute lung injury or acute respiratory distress syndrome (ARDS) since the early 1970s. Prone position and extended prone position ventilation have been shown to increase end-expiratory lung volume, alveolar recruitment, and oxygenation in patients with severe hypoxemic and acute respiratory failure. Prone positioning is not a benign procedure, and there are potential risks (complications) that can occur to both the patient and the health care worker. Notable complications that can arise include: unplanned extubation, lines pulled, tubes kinked, and back and other injuries to personnel. Prone positioning is a viable, inexpensive therapy for the treatment of severe ARDS. This maneuver consistently improves systemic oxygenation in 70% to 80% of patients with ARDS. With the utilization of a standardized protocol and a trained and dedicated critical care staff, prone positioning can be performed safely.

Counterpoint: Residual Neuromuscular Blockade in the PACU—A Continuing Serious Problem

SKELETAL MUSCLE WEAKNESS from residual neuromuscular blockade (NMB) is a significant cause of early adverse respiratory events in the postanesthesia care unit (PACU). This finding from a recent study highlights a preventable cause of morbidity and significant discomfort in patients recovering from general anesthesia. Although this opens up the need for further nursing education and safety processes, the commentary by Dr. Petty in the preceding article, ‘‘Residual Neuromuscular Blockade in the PACU: A Continuing Serious Problem,’’ deserves further scrutiny.

Lending a Hand to Improve Hand Hygiene (HH)

 Process of implementation o PACU educators assessed problem and received commitment from management for resources o Report out data to pacu staff by posting data graphs o Posted/emailed evidence based articles o Staff completed on-line learning module o PACU educators taught auditors daily o Charge nurses assigned auditor daily, reports submitted before deadline, exceeded requirement o Posted blank audit forms for easy access, deposit envelope for completed audits o Reminder signs posted o PACU educators monitored audits to insure completion and submitted monthly o Reward 3 months of 100% compliance with pizza party

Practical Thoughts: Bringing Online Documentation Into Your World

THE THOUGHT OF BRINGING a new information system up live or taking down an old one and replacing it with something else brings joy to some and fear to others. But to all it brings the certain knowledge that the ways in which tasks are currently done, the ways in which care is rendered for patients, and the mechanisms through which we communicate with the health care team will certainly and fundamentally change. And although the change may be needed, it is still a change, and that is not a comfortable thought for most of us. In addition, it is known that implementations of these systems can result in unintended consequences, both positive and negative, that can have profound impact on the health care environment and, subsequently, the safety of patients and the efficiency of staff. The most significant of these consequences are related to new/more work, workflow, system demands, communications, emotions, and dependence on technology.

Computer and information technology: Software

You have that new computer and you are ready to start computing, right? Not quite. There is another essential to get started--software. This article focuses on software necessary and nice for your computer, and resources that can help you in your quest for creating the best possible and easiest to use computer system. Once you have gotten everything installed and functioning, you will be ready to take the next step--going online. In the next issue of the Journal we will get you online and traveling on the information superhighway. Happy computing!

Essentials: Going online

The moment has arrived for you to go online! This article provides an overview of online access and Internet services. Resources are suggested and hints are offered to get the novice started on the information highway. Enjoy your journey!