Rochelle Armola

The Minnesota Living with Heart Failure Questionnaire: Sensitivity to differences and responsiveness to intervention intensity in a clinical population

BackgroundThe Minnesota Living With Heart Failure Questionnaire (LHFQ) is a commonly used measure of health-related quality of life in persons with heart failure. Researchers have questioned whether LHFQ is sensitive to subtle differences and sufficiently responsive to clinical interventions because the instrument has demonstrated variable performance in clinical trials. ObjectivesA secondary analysis was conducted to assess the LHFQ for sensitivity to different clinical states and responsiveness to varying intensities of clinical intervention. MethodsA convenience sample of nine experimental or quasi-experimental studies from eight clinical sites in the United States yielded data from 1,136 patients with heart failure. Data in the studies had been collected at enrollment and one, three, and/or six months later. Data were analyzed using descriptive, univariate, and multivariate techniques. ResultsTotal and subscale scores on LHFQ were poorer in those with worse New York Heart Association functional class, although there was no difference in LHFQ scores between classes III and IV. No difference in LHFQ scores was found when patients were classified by ejection fraction. Scores improved significantly following hospital discharge, even in those in the control group. Changes in LHFQ scores were greatest in those receiving high intensity interventions. ConclusionsThe LHFQ is sensitive to major differences in symptom severity but may not be sensitive to subtle differences. It is responsive to high intensity interventions. Investigators are cautioned against using this instrument without first maximizing intervention power or without a control group for comparison.

Symptom Clusters of Heart Failure

Patients with heart failure (HF) report multiple symptoms. Change in symptoms is an indicator of HF decompensation. Patients have difficulty differentiating HF symptoms from comorbid illness or aging. The study purpose was to identify the number, type, and combination of symptoms in hospitalized HF patients and test relationships with comorbid illness and age. A secondary analysis from a HF registry (N = 687) was conducted. The sample was 51.7% female, mean age 71 +/- 12.5 years. The theory of unpleasant symptoms informed the study regarding the multidimensional nature of symptoms. Factor analysis of nine items from the Minnesota Living with HF Questionnaire resulted in three factors, acute and chronic volume overload and emotional distress. Clusters occurred more frequently in older patients, but caused less impact.

AACN Levels of Evidence: What’s New?

tice related to disease management or skills. As a leader in this area, the American Association of CriticalCare Nurses (AACN) has published numerous resources to help practitioners appraise evidence for integration into clinical practice. Publications such as Practice Alerts, Protocols for Practice, and Procedure Manual contain recommendations for clinical practice based on a comprehensive and scientific review of the evidence. To support these recommendations, AACN developed a hierarchy system to grade the level of evidence. AACN’s grading system was originally referred to as a rating scale and was used to rank individual recommendations according to the level of supporting evidence available (Table 1).

Ethnic differences in quality of life in persons with heart failure

BACKGROUND Chronic illness burdens some groups more than others. In studies of ethnic/racial groups with chronic illness, some investigators have found differences in health-related quality of life (HRQL), whereas others have not. Few such comparisons have been performed in persons with heart failure. The purpose of this study was to compare HRQL in non-Hispanic white, black, and Hispanic adults with heart failure. METHODS Data for this longitudinal comparative study were obtained from eight sites in the Southwest, Southeast, Northwest, Northeast, and Midwest United States. Enrollment and 3- and 6-month data on 1212 patients were used in this analysis. Propensity scores were used to adjust for sociodemographic and clinical differences among the ethnic/racial groups. Health-related quality of life was measured using the Minnesota Living with Heart Failure Questionnaire. RESULTS Significant ethnic/racial effects were demonstrated, with more favorable Minnesota Living with Heart Failure Questionnaire total scores post-baseline for Hispanic patients compared with both black and white patients, even after adjusting for baseline scores, age, gender, education, severity of illness, and care setting (acute vs. chronic), and estimating the treatment effect (intervention vs. usual care). The models based on the physical and emotional subscale scores were similar, with post hoc comparisons indicating more positive outcomes for Hispanic patients than non-Hispanic white patients. CONCLUSION Cultural differences in the interpretation of and response to chronic illness may explain why HRQL improves more over time in Hispanic patients with heart failure compared with white and black patients.

Effect of Oral Care on Bacterial Colonization and Ventilator-Associated Pneumonia

Critical care nurses are mindful of the need for oral care in patients receiving mechanical ventilation. The Centers for Disease Control and Prevention (CDC) recommend comprehensive oral hygiene programs (potentially including antiseptic agents) for patients at risk for nosocomial pneumonia. The Centers for Medicare and Medicaid Services (CMS) have recently identified 10 “neverevent” diagnoses with hospital reimbursement implications. CMS has indicated that it will create a code to identify ventilator-associated pneumonia (VAP) as a future preventable hospital-acquired condition. Nosocomial pneumonia has been correlated with dental plaque and oropharynx colonization in patients receiving mechanical ventilation. Oropharyngeal flora and microbes undergo changes within 48 hours of admission to the intensive care unit (ICU). Endotracheal tubes most likely serve as conduits for colonization because these same microorganisms can be traced to respiratory infections. Subglottal suctioning of secretions lying above the endotracheal cuff has proven effective in reducing rates of VAP. Although many believe that oral care regimens reduce oropharyngeal colonization, insufficient research exists on the impact of such regimens on VAP. In this review, we summarize the current evidence on the effect that oral care has on dental plaque, oropharyngeal colonization, and nosocomial pneumonia in patients receiving mechanical ventilation.

Chlorhexidine Gluconate Bathing: Does it Decrease Hospital-Acquired Infections?

As pay for performance becomes more prevalent, hospitals struggle to improve processes, especially those for preventing hospitalacquired infections (HAIs). Many hospital programs seek out evidence-based “best practices” to keep patients safe from deadly and costly HAIs. Critical care nurses have begun examining even the most rudimentary tasks, such as bathing patients, and the processes inherently associated with them. It has been suggested that a bathing procedure that focuses on decolonization may decrease HAI rates. This procedure routinely includes administration of a nasal antibacterial agent and then bathing patients with a solution of 2% to 4% chlorhexidine gluconate, each for a series of days. It has also been suggested that bath basins may be a source of bacterial transmission. Further, use of a bath basin may lead to contamination of other items such as the sink for hand washing. These suggestions bring into focus several important steps that nurses must take to help keep patients safe from HAIs, although we cannot assume that these few steps are the complete answer for prevention. The Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America have developed a compendium of recommendations to prevent transmission of multidrug-resistant organisms and HAIs in acute care hospitals. The idea is that if procedures outlined in the compendium are performed, HAIs such as ventilator-associated A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.

THE "COLD CORD": A REVIEW OF THERAPEUTIC HYPOTHERMIA FOR TRAUMATIC SPINAL CORD INJURIES

A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.