Mary S. McCarthy

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (sccm) and American Society for Parenteral and Enteral Nutrition (a.s.p.e.n.)

A.S.P.E.N. and SCCM are both nonprofit organizations composed of multidisciplinary healthcare professionals. The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. The mission of SCCM is to secure the highest quality care for all critically ill and injured patients. Guideline Limitations: These A.S.P.E.N.−SCCM Clinical Guidelines are based on general conclusions of health professionals who, in developing such guidelines, have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy. However, practice guidelines are not intended as absolute requirements. The use of these practice guidelines does not in any way project or guarantee any specific benefit in outcome or survival. The judgment of the healthcare professional based on individual circumstances of the patient must always take precedence over the recommendations in these guidelines. The guidelines offer basic recommendations that are supported by review and analysis of the current literature, other national and international guidelines, and a blend of expert opinion and clinical practicality. The population of critically ill patients in an intensive care unit (ICU) is not homogeneous. Many of the studies on which the guidelines are based are limited by sample size, patient heterogeneity, variability in disease severity, lack of baseline nutritional status, and insufficient statistical power for analysis. Periodic Guideline Review and Update: This particular report is an update and expansion of guidelines published by A.S.P.E.N. and SCCM in 2009 (1). Governing bodies of both A.S.P.E.N. and SCCM have mandated that these guidelines be updated every three to five years. The database of randomized controlled trials (RCTs) that served as the platform for the analysis of the literature was assembled in a joint “harmonization process” with the Canadian Clinical Guidelines group. Once completed, each group operated separately in their interpretation of the studies and derivation of guideline recommendations (2). The current A.S.P.E.N. and SCCM guidelines included in this paper were derived from data obtained via literature searches by the authors through December 31, 2013. Although the committee was aware of landmark studies published after this date, these data were not included in this manuscript. The process by which the literature was evaluated necessitated a common end date for the search review. Adding a last-minute landmark trial would have introduced bias unless a formalized literature search was re-conducted for all sections of the manuscript. Target Patient Population for Guideline: The target of these guidelines is intended to be the adult (≥ 18 years) critically ill patient expected to require a length of stay (LOS) greater than 2 or 3 days in a medical ICU (MICU) or surgical ICU (SICU). The current guidelines were expanded to include a number of additional subsets of patients who met the above criteria, but were not included in the previous 2009 guidelines. Specific patient populations addressed by these expanded and updated guidelines include organ failure (pulmonary, renal, and liver), acute pancreatitis, surgical subsets (trauma, traumatic brain injury [TBI], open abdomen [OA], and burns), sepsis, postoperative major surgery, chronic critically ill, and critically ill obese. These guidelines are directed toward generalized patient populations but, like any other management strategy in the ICU, nutrition therapy should be tailored to the individual patient. Target Audience: The intended use of these guidelines is for all healthcare providers involved in nutrition therapy of the critically ill, primarily physicians, nurses, dietitians, and pharmacists. Methodology: The authors compiled clinical questions reflecting key management issues in nutrition therapy. A committee of multidisciplinary experts in clinical nutrition composed of physicians, nurses, pharmacists, and dietitians was jointly convened by the two societies.

The association of shift-level nurse staffing with adverse patient events

Objective: The objective of this study was to demonstrate the association between nurse staffing and adverse events at the shift level. Background: Despite a growing body of research linking nurse staffing and patient outcomes, the relationship of staffing to patient falls and medication errors remains equivocal, possibly due to dependence on aggregated data. Methods: Thirteen military hospitals participated in creating a longitudinal nursing outcomes database to monitor nurse staffing, patient falls and medication errors, and other outcomes. Unit types were analyzed separately to stratify patient and nurse staffing characteristics. Bayesian hierarchical logistic regression modeling was used to examine associations between staffing and adverse events. Results: RN skill mix, total nursing care hours, and experience, measured by a proxy variable, were associated with shift-level adverse events. Conclusions: Consideration must be given to nurse staffing and experience levels on every shift.

A Retrospective, Descriptive, Exploratory Study Evaluating Incidence of Postoperative Urinary Retention After Spinal Anesthesia and Its Effect on PACU Discharge

Postoperative urinary retention (POUR) is a common problem that occurs at rates ranging from 7% to 52%. It is uncertain exactly what patient-related or surgery factors may influence POUR. This retrospective, descriptive, exploratory study of 102 patients examined the incidence of POUR, its impact on length-of-stay, and the patient/procedural characteristics that are associated with POUR. The incidence of POUR in our facility was found to be 44.1%. Length-of-stay in the PACU was 26 minutes longer for patients with POUR; although not statistically significant, this was clinically significant. Mean bladder volume on admission to the PACU was 467.6 mL (range, 0 to 1000 mL) with >500 mL associated with POUR, chi(2) = .00. A protocol for draining the patients bladder at the end of the surgical procedure or immediately upon admission to the PACU could be beneficial to both patients and PACU nursing staff by reducing patient discomfort and length-of-stay.

Towards Evidence-based Management: Creating an Informative Database of Nursing-Sensitive Indicators

PURPOSE The purpose of this paper is to describe the creation, evolution, and implementation of a database of nursing-sensitive and potentially nursing-sensitive indicators, the Military Nursing Outcomes Database (MilNOD). It discusses data quality, utility, and lessons learned. DESIGN/METHODS Prospective data collected each shift include direct staff hours by levels (i.e., registered nurse, other licensed and unlicensed providers), staff categories (i.e., military, civilian, contract, and reservist), patient census, acuity, and admissions, discharges, and transfers. Retrospective adverse event data (falls, medication errors, and needle-stick injuries) were collected from existing records. Annual patient satisfaction, nurse work environment, and pressure ulcer and restraint prevalence surveys were conducted. FINDINGS AND CONCLUSIONS The MilNOD contains shift level data from 56 units in 13 military hospitals and is used to target areas for managerial and clinical performance improvement. This methodology can be modified for use in other healthcare systems. CLINICAL RELEVANCE As standard tools for evidence-based management, databases such as MilNOD allow nurse leaders to track the status of nursing and adverse events in their facilities.

Exploring factors associated with pressure ulcers: A data mining approach

BACKGROUND Pressure ulcers are associated with a nearly three-fold increase in in-hospital mortality. It is essential to investigate how other factors besides the Braden scale could enhance the prediction of pressure ulcers. Data mining modeling techniques can be beneficial to conduct this type of analysis. Data mining techniques have been applied extensively in health care, but are not widely used in nursing research. PURPOSE To remedy this methodological gap, this paper will review, explain, and compare several data mining models to examine patient level factors associated with pressure ulcers based on a four year study from military hospitals in the United States. METHODS The variables included in the analysis are easily accessible demographic information and medical measurements. Logistic regression, decision trees, random forests, and multivariate adaptive regression splines were compared based on their performance and interpretability. RESULTS The random forests model had the highest accuracy (C-statistic) with the following variables, in order of importance, ranked highest in predicting pressure ulcers: days in the hospital, serum albumin, age, blood urea nitrogen, and total Braden score. CONCLUSION Data mining, particularly, random forests are useful in predictive modeling. It is important for hospitals and health care systems to use their own data over time for pressure ulcer risk prediction, to develop risk models based upon more than the total Braden score, and specific to their patient population.

Perioperative immunonutrition in head and neck cancer.

Immune‐modulating nutrition (IMN) support before and after surgery has the potential to promote host defense, antitumor activities, and wound healing. The purpose of this study was to examine the nutritional, immunologic, and wound healing outcomes in patients receiving IMN versus standard formula.

Special Nutrition Challenges: Current Approach to Acute Kidney Injury

Acute kidney injury (AKI), previously known as acute renal failure, is defined as a sudden decline in glomerular filtration rate with accumulation of metabolic waste products, toxins, and drugs, as well as alteration in the intrinsic functions of the kidney. Reports of mortality are as high as 80%, with numerous contributing causes including infection, cardiorespiratory complications, and cardiovascular disease. Concurrent with the high prevalence of critical illness in this population is the protein energy wasting (PEW), seen in up to 42% of patients upon intensive care unit admission. The pathophysiologic derangements of critical illness, the low energy and protein stores, and uremic complications require early nutrition intervention to attenuate the inflammatory response and oxidative stress, improve endothelial function, stabilize blood sugar, and preserve lean body mass. This article addresses the unique challenges of nutrition support for the patient with AKI in the setting of critical illness and renal replacement therapy. Evidence-based recommendations are provided to meet the macronutrient and micronutrient requirements of this heterogeneous and complex patient population.

Subglottic Secretion Drainage A Literature Review

Ventilator-associated pneumonia is a costly complication of hospitalization that lengthens intensive care unit and hospital stay, increasing morbidity and mortality. Among evidence-based measures to prevent ventilator associated pneumonia is the use of a specialized endotracheal tube that aspirates subglottic secretions. Recommendations for subglottic aspiration are found in guidelines by the Centers for Disease Control and Prevention, American Association of Critical-Care Nurses, and the American Thoracic Society. The purpose of this article is to review the available evidence regarding the use of an endotracheal tube with a subglottic secretion aspiration port to prevent ventilator-associated pneumonia. Issues, cost, benefits, and research recommendations will also be discussed.

A prospective randomized study of the effectiveness of aromatherapy for relief of postoperative nausea and vomiting

INTRODUCTION Postoperative nausea and vomiting (PONV) is a major concern for patients having surgery under general anesthesia as it causes subjective distress along with increased complications and delays in discharge from the hospital. Aromatherapy represents a complementary and alternative therapy for the management of PONV. PURPOSE The objective of this study was to compare the effectiveness of aromatherapy (QueaseEase, Soothing Scents, Inc, Enterprise, AL) versus an unscented inhalant in relieving PONV. METHODS One hundred twenty-one patients with postoperative nausea were randomized into a treatment group receiving an aromatic inhaler and a control group receiving a placebo inhaler to evaluate the effectiveness of aromatherapy. FINDINGS Initial and follow-up nausea assessment scores in both treatment and placebo groups decreased significantly (P < .01), and there was a significant difference between the two groups (P = .03). Perceived effectiveness of aromatherapy was significantly higher in the treatment group (P < .001). CONCLUSIONS Aromatherapy was favorably received by most patients and represents an effective treatment option for postoperative nausea.

Participation in a national nursing outcomes database: monitoring outcomes over time.

The current and future climates in health care require increased accountability of health care organizations for the quality of the care they provide. Never before in the history of health care in America has this focus on quality been so critical. The imperative to measure nursings impact without fully developed and tested monitoring systems is a critical issue for nurse executives and managers alike. This article describes a project to measure nursing structure, process, and outcomes in the military health system, the Military Nursing Outcomes Database project. Here we review the effectiveness of this project in monitoring changes over time, in satisfying expectations of nurse leaders in participating hospitals, and evaluate the potential budgetary impacts of such a system. We conclude that the Military Nursing Outcomes Database did meet the needs of a monitoring system that is sensitive to changes over time in outcomes, provides interpretable data for nurse leaders, and could result in cost benefits and patient care improvements in organizations.