Diane J. Mick

Technologic approaches to determining proper placement of enteral feeding tubes.

E delivery of nutritional support is an important component of overall management of critically ill patients. In the presence of a functioning gastrointestinal (GI) tract, enteral nutrition generally is preferred over parenteral nutrition, as it is less expensive, and also may help to reduce infectious complications. Early enteral nutrition in the intensive care unit (ICU) has been shown to decrease bacterial translocation from the intestinal tract while preserving gut barrier function and enhancing its role as an immune organ. Research also has demonstrated that early enteral feeding enhances nitrogen balance and wound healing, decreases hypermetabolic response to tissue injury, and augments cellular antioxidant systems, resulting in an overall decrease in the incidence of sepsis. Therefore, access to the small bowel is essential to improve outcomes for critically ill patients. However, critically ill patients are at high risk for adverse outcomes from clinical mishaps associated with feeding tube insertion. Complications from malpositioning of feeding tubes have included “isocalothorax,” resulting from feedings instilled into the lungs rather than into the GI tract, and pneumothorax following feeding tube placement with the use of a guidewire. Other complications associated with both the insertion and use of enteral feeding tubes include atelectasis, pleural effusion, bronchopleural fistula, hydrothorax, empyema, mediastinitis, pneumonitis, esophageal perforation, and pneumonia. Predisposing factors, such as the presence of an endotracheal tube or tracheostomy, altered mental status, decreased ability to comply with instructions during procedures, and hampered ability to report chest discomfort or dyspnea following feeding tube insertion, are additional factors that warrant serious consideration in the search for new empirically validated techniques for ensuring patient safety and optimal nutritional outcomes in the ICU.

Neutralizing ageism in critical care via outcomes research.

Ageism, as a mind-set, amplifies a belief that intensive care for the elderly is ineffectual. However, there are little data to support the notion that advanced chronological age alone predicts unfavorable outcomes in response to intensive care. A lack of outcome data, combined with ageism, may place older patients at risk for rationing of intensive care. Currently, neither public policy nor cultural norms directly support a limitation in services to the elderly. However, as pressure to reduce health care costs increases, critically ill elderly patients may be targeted for rationing. In this context, outcomes research involving elderly populations is crucial. The purpose of this report is to explicate the risk of ageism in the delivery of intensive care and to describe methods for implementing outcomes assessment for critically ill elderly patients as an essential element in a continuum of care.

Creating an organizational model to support advanced practice.

The growing number of advanced practice providers in hospital systems has necessitated the establishment of centralized coordinating centers to manage core functions related to regulatory requirements and credentialing and to provide resources for research and evidence-based practice and practice model innovation. The Margaret D. Sovie Center for Advanced Practice was created at the University of Rochester Medical Center to meet these demands of more than 350 nurse practitioners. The authors describe the structure and functions of the center.

Nursing and biomedical engineering transdisciplinary clinical trials collaboration.

Diane J Mick, PhD, RN, FNAP Michael H Ackerman, DNS, RN, FCCM, FNAP Author for correspondence University of Rochester, Center for Clinical Trials and Medical Device Evaluation, Rochester, NY, USA Diane_Mick@URMC.Rochester.edu ‘As physician researchers typically have delegated the responsibilities of clinical trial research coordination to nurses, nursing roles in clinical research have evolved into a subspecialty both within and parallel to the nursing profession.’

Pneumonia in elders

In spite of the availability of potent antibiotics and sophisticated diagnostic techniques, pneumonia continues to be a serious problem among elders. Respiratory infections occur frequently and often are complex. Management is complicated by atypical clinical presentations and altered metabolism of pharmacologic agents. Community-acquired pneumonia and nosocomial pneumonia are caused by different organisms but can have similar clinical presentations. Current therapeutic measures and appropriateness of hospitalization are discussed. Via synthesis and application of this material, nurses can maximize positive outcomes by identifying symptoms, individualizing care, and implementing effective preventive education in the acute care setting, as well as in the community.