Jan Powers

Verification of an Electromagnetic Placement Device Compared With Abdominal Radiograph to Predict Accuracy of Feeding Tube Placement

BACKGROUND Use of an electromagnetic placement device (EMPD) facilitates placement of feeding tubes at the bedside. Standard practice for verification of feeding tube placement is via radiographic confirmation. The purpose of this research study was to assess the accuracy of placement of small-bore feeding tubes (SBFTs) as determined by EMPD interpretation compared with that of abdominal radiograph verification by a radiologist. METHODS This multicenter prospective study enrolled patients requiring bedside feeding tube placement. SBFTs were placed by an experienced investigator using the EMPD. Two abdominal radiographs were then obtained: one after initial SBFT placement and an additional radiograph after injection of contrast. Documentation of location based on clinician interpretation using the EMPD was then compared with radiologist interpretation. RESULTS The final sample size was 194 patients, including 18 pediatric patients. Patient age ranged from 12 days to 102 years. Median time for tube placement was 12 minutes. Of the 194 patients, only 1 patient had data showing discrepancies between the original EMPD verification and the final abdominal radiograph interpretation, providing a 99.5% agreement. No patient experienced complications during SBFT placement, and 15 patients had inadvertent airway placement that was avoided with the use of the EMPD. CONCLUSIONS There was a high percentage of agreement between EMPD and radiologic interpretation after contrast injection. The EMPD aided in avoiding inadvertent airway placement, with no patient complications. This device can be used safely at the bedside to facilitate placement of feeding tubes, leading to the delivery of early enteral nutrition.

Elimination of Radiographic Confirmation for Small-Bowel Feeding Tubes in Critical Care

BACKGROUND A variety of techniques are used for placement of small-bowel feeding tubes. Standard practice at the study institution is for postpyloric placement using an electromagnetically guided placement device (EMPD). EMPD placement is performed by bedside nurses trained in the placement technique and may reduce radiograph exposures and time to initiation of enteral nutrition. OBJECTIVES To evaluate how changes in SBFT placement verification procedures in critical care patients-from use of EMPD with radiographic confirmation, to placement verification by using EMPD without radiographic confirmation-influenced successful placement, misinterpretations of locations, and radiographic verification of tube locations. METHODS The research was conducted at an 800-bed quaternary care referral hospital located in the Midwest. Nine-hundred four feeding tubes were placed in 632 critical care patients by using bedside EMPD instead of radiographic confirmation as the standard of care. Prospectively collected EMPD audit form data were retrospectively analyzed. RESULTS Small-bowel (duodenum or jejunum) placement was achieved by bedside nurses in 97.2% of all EMPD placements, with 2.8% placed in the stomach because gastric placement was ordered or small-bowel placement could not be achieved. Radiographic confirmation was required in only 7.7% of placements. No adverse events or pulmonary placements occurred. CONCLUSIONS Use of EMPD technology allowed clinicians to safely and effectively place feeding tubes at the bedside and eliminate radiographs in most cases. EMPD placement was not limited to specialized nurses or teams. This procedure should be easily reproducible in other critical care environments.

A comparative evaluation of antimicrobial coated versus nonantimicrobial coated peripherally inserted central catheters on associated outcomes: A randomized controlled trial

BACKGROUND Central line-associated bloodstream infections (CLABSIs) are a common life-threatening risk factor associated with central venous catheters (CVCs). Research has demonstrated benefit in reducing CLABSIs when CVCs coated with antimicrobials are inserted. The impact of chlorhexidine (CHG)-impregnated versus non-CHG peripherally inserted central catheters (PICCs) on risk of CLABSI is unknown. Venous thromboembolism (VTE) is also a complication associated with CVCs. This study compares the impact of both PICC lines on these outcomes. METHODS Patients in 3 high-risk units were randomly assigned to receive either a CHG-impregnated or non-CHG PICC line. Laboratory data were collected and reviewed daily on all study patients. The PICC dressing site was assessed daily. Medical record documentation was reviewed to determine presence of CLABSI or VTE. RESULTS There were 167 patients who completed the study. Three patients developed CLABSI (2 in the CHG group, and 1 in the non-CHG group), and 3 patients developed VTE (2 in the non-CHG group, and 1 in the CHG group). No significant relationship was noted between the type of PICC line on development of a CLABSI (P = .61) or VTE (P > .99). A significant difference was noted in moderate bleeding (P ≤ .001) requiring thrombogenic dressing in the patients who had the CHG PICC line. CONCLUSIONS No differences were noted in the development of CLABSI and VTE between the CHG and non-CHG groups.

Improved Outcomes Associated with the Liberal Use of Thoracic Epidural Analgesia in Patients with Rib Fractures

Objective Each year, more than 150,000 patients with rib fractures are admitted to US trauma centers; as many as 10% die. Effective pain control is critical to survival. One way to manage pain is thoracic epidural analgesia. If this treatment reduces mortality, more frequent use may be indicated. Methods We analyzed the patient registry of a level II trauma center. All patients admitted with one or more rib fractures (N = 1,347) were considered. Patients who were not candidates for epidural analgesia (N = 382) were eliminated. Mortality was assessed with binary logistic regressions. Results Across the total population, mortality was 6.7%; incidence of pneumonia was 11.1%; mechanical ventilation was required in 23.8% of patients, for an average duration of 10.0 days; average stay in the hospital was 7.7 nights; and 49.7% of patients were admitted to the ICU for an average of 7.2 nights. Epidural analgesia was administered to 18.4% of patients. After matching samples for candidacy, patients who received epidurals were 3.7 years older, fractured 2.6 more ribs, had higher injury severity scores, and were more likely to present with bilateral fractures, flail segments, pulmonary contusions, hemothoraces, and pneumothoraces. Despite greater injury severity, mortality among these patients was lower (0.5%) than those who received alternative care (1.9%). Controlling for age, injury severity, and use of mechanical ventilation, epidural analgesia predicted a 97% reduction in mortality. Conclusion Thoracic epidural analgesia associates with reduced mortality in rib fracture patients. Better care of this population is likely to be facilitated by more frequent reliance on this treatment.

Malnutrition in the ICU Patient Population

Malnutrition has been identified as a cause for disease as well as a condition resulting from inflammation associated with acute or chronic disease. Malnutrition is common in acute-care settings, occurring in 30% to 50% of hospitalized patients. Inflammation has been associated with malnutrition and malnutrition has been associated with compromised immune status, infection, and increased intensive care unit (ICU) and hospital length of stay. The ICU nurse is in the best position to advocate for appropriate nutritional therapies and facilitate the safe delivery of nutrition.

Implications of Thoracic Epidural Analgesia on Hospital Charges in Rib Fracture Patients

Objective Rib fractures are present in more than 150,000 patients admitted to US trauma centers each year. Those who fracture two or more ribs are typically treated with oral analgesic drugs and are discharged with few complications. The cost of this care generally reflects its brevity. When a patient fractures three or more ribs, there is an elevated risk of complication. In response, treatments are often broadened and their durations prolonged; this affects cost. While health, function, and survival have been widely explored, patient billing has not. Thus, we evaluated the financial implications of one mode of treatment for patients with rib fractures: thoracic epidural analgesia (TEA). Methods We retrospectively analyzed the registry of a level II trauma center. All patients who fractured one or more ribs (n = 1,344) were considered; 382 of those patients were not candidates for epidural placement and were eliminated from analyses. Epidural placement was determined by individual clinicians. We used multiple linear regressions to determine predictors of cost. Results After eliminating patients who were not eligible to receive TEA, the average patient bill was

Use of Gastric Decompression Tubes With Small-Bowel Feeding Tubes

59,123 (

Improved Safety and Efficacy of Small-Bore Feeding Tube Confirmation Using an Electromagnetic Placement Device

10,631 per day of treatment). The administration of TEA predicted a 25% reduction in total billing (99% CI = -

Bedside Placement of Small-Bowel Feeding Tubes In the Intensive Care Unit

21,429.55- -

Chlorhexidine Bathing and Microbial Contamination in Patients’ Bath Basins

7,794.66) and a 24% reduction in per-day billing (99% CI = -