Ellen H. Elpern

Reducing Use of Indwelling Urinary Catheters and Associated Urinary Tract Infections

BACKGROUND Use of indwelling urinary catheters can lead to complications, most commonly catheter-associated urinary tract infections. Duration of catheterization is the major risk factor. These infections can result in sepsis, prolonged hospitalization, additional hospital costs, and mortality. OBJECTIVES To implement and evaluate the efficacy of an intervention to reduce catheter-associated urinary tract infections in a medical intensive care unit by decreasing use of urinary catheters. METHODS Indications for continuing urinary catheterization with indwelling devices were developed by unit clinicians. For a 6-month intervention period, patients in a medical intensive care unit who had indwelling urinary catheters were evaluated daily by using criteria for appropriate catheter continuance. Recommendations were made to discontinue indwelling urinary catheters in patients who did not meet the criteria. Days of use of a urinary catheter and rates of catheter-associated urinary tract infections during the intervention were compared with those of the preceding 11 months. RESULTS During the study period, 337 patients had a total of 1432 days of urinary catheterization. With use of guidelines, duration of use was significantly reduced to a mean of 238.6 d/mo from the previous rate of 311.7 d/mo. The number of catheter-associated urinary tract infections per 1000 days of use was a mean of 4.7/mo before the intervention and zero during the 6-month intervention period. CONCLUSIONS Implementation of an intervention to judge appropriateness of indwelling urinary catheters may result in significant reductions in duration of catheterization and occurrences of catheter-associated urinary tract infections.

Pulmonary aspiration in hospitalized adults.

Until recent years, pulmonary aspiration attracted remarkably little clinical investigation. Although aspiration was considered a common occurrence in hospitalized individuals, with serious and even fatal consequences, clinicians had limited scientific data to guide practice. Consequently, approaches to this problem were based largely on unsystematic observations, intuition, and tradition. Recent investigations on the subjects of aspiration have increased our understanding of patients at risk for aspiration, the value of diagnostic methods, and the efficacy of interventions to prevent or limit aspirations. Results of these studies call to question many time-honored adages and practices. Considerable uncertainty remains and more investigation is necessary before management decisions can be characterized clearly and clinical strategies defined. This review focuses on pulmonary aspiration and enteral feeding in the critically ill adult. Factors implicated in aspiration in this population are highlighted and evidence to support the application of interventions prescribed commonly is presented.

Improving outcomes: focus on workplace issues.

Purpose of reviewStaff satisfaction has not traditionally been included as an intensive care unit quality indicator. The process of providing intensive care may profoundly affect clinicians. Dysfunctional encounters with coworkers and ethical burdens may extract a considerable personal toll and affect work attitudes and performance. Recent findingsMounting evidence indicates that psychosocial tensions, burnout and ethical stress are common and serious problems in the intensive care unit. These experiences impact negatively on job satisfaction, turnover, workplace disruption and patient care. Addressing workplace issues will help improve quality of care. SummaryTwo common sources of staff dissatisfaction are examined. Improving staff satisfaction can improve unit performance, and serve to attract and retain quality clinicians.

The application of intermittent pneumatic compression devices for thromboprophylaxis: AN observational study found frequent errors in the application of these mechanical devices in ICUs.

Objective Because venous thromboembolism (VTE) can be a devastating consequence of critical illness, patients should receive thromboprophylaxis using chemical or mechanical strategies or both. Mechanical strategies such as intermittent pneumatic compression (IPC) devices are in widespread use; this study sought to assess clinicians’ adherence to ordered IPC devices in critically ill patients. Methods A month-long prospective, observational study was conducted in a convenience sample of 108 mechanically ventilated patients in four adult ICUs in an urban academic medical center. Observations of prescribed IPC device applications were made twice daily by nurses using a standardized checklist. Results Nine hundred sixty-six observations were made of 108 patients, 47 (44%) of whom were ordered to receive thromboprophylaxis with IPC devices alone and 61 (56%) to receive IPC devices in combination with an anticoagulant. Errors in IPC device application were found in 477 (49%) of the observations. Patients received no IPC prophylaxis in 142 (15%) of total observations. In 45 of 342 (13%) of the observations, IPC devices were the only type of thromboprophylaxis ordered. Half of the misapplications related to improper placement of sleeves to legs. Misapplications did not differ in type or frequency between shifts. Implications The researchers observed frequent misapplications of ordered IPC devices. Future study is necessary to illuminate the consequences of such errors.

Loss of pulmonary function gains after lung volume reduction surgery

Lung volume reduction surgery (LVRS) has been demonstrated to improve lung function, exercise tolerance and quality of life. However, the duration of improvement is unknown. While the maximal duration of improvement cannot be determined at this time due to an inadequate period of follow-up, we have observed in some patients significant and relatively rapid declines in gains following LVRS. We describe 6 patients who increased FEV1 by at least 10% of the predicted value after LVRS and subsequently experienced rapid loss of the increment in FEV1 (mean loss 79%, 95% CI 58-100%) over a period ranging from 14 to 20 months following surgery.

Inpatient Care of the Adult With an Exacerbation of Cystic Fibrosis

Patients with cystic fibrosis (CF) are living longer, albeit with chronic and progressive lung disease. Pulmonary exacerbations in CF are characterized by an increase in respiratory symptoms and a decrease in pulmonary function and gas exchange. Exacerbations that do not respond to outpatient management require hospitalization. Complications of CF can be devastating and life-threatening. Care of these patients is challenging not only because of the scope and severity of their medical problems, but also because of the need to coordinate services and to maintain continuity during transitions between hospital and home.

Community-acquired pneumonia: updates in assessment and management.

Community-acquired pneumonia (CAP) is a significant health condition. Knowledge of the clinical presentation and treatment of CAP are important for critical care nurses as up to 20% of patients with CAP require hospitalization and in-patient management. Patients with severe CAP requiring intensive care unit (ICU) treatment often require aggressive management including mechanical ventilation and multisystem organ support. This article presents an overview of CAP, including the presentation of typical and atypical CAP, clinical findings, and the essentials of management. Treatment differences between CAP and healthcare-acquired pneumonia and nursing implications are also highlighted.