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Biomedical subjects

Pamela H Mitchell

Publications and source records attributed to Pamela H Mitchell.

At least 19 recordsLinked to original sources
PubMed2007

Intensive care unit management of fever following traumatic brain injury.

Fever, in the presence of traumatic brain injury (TBI), is associated with worsened neurologic outcomes. Studies prior to the publication of management guidelines revealed an undertreatment of fever in patients with neurologic insults. Presently the adult TBI guidelines state that maintenance of normothermia should be a standard of care therefore improvement in management of fever in these patients would be expected. The specific aims of the study were to: (1) determine the incidence of fever (T>or=38.5 degrees C) in a population of critically ill patients with TBI; (2) describe what interventions were recorded by intensive care unit (ICU) nurses in managing fever; (3) ascertain the rate of adherence with published normothermia guidelines. Medical record review of available hospital records was conducted on patients admitted to a level I trauma center following severe TBI (N=108) from the parent study. Temperature data was abstracted and contemporaneous nursing documentation was examined for evidence of intervention for fever and adherence with published standards. Data analyses were performed that included descriptive statistics. Seventy-nine percent of TBI patients (85/108) had at least one recorded fever event while in the ICU. However in only 31% of events did the patient receive any documented intervention by nursing staff for the elevated temperature. The most frequently documented intervention was pharmacologic (358/1166 elevations). Other nursing actions (e.g. use of fan) accounted for a minority (<1%) of nursing interventions documented. Patients were more likely to have a high temperature that exceeded 40 degrees C (13%) than a temperature that was normothermic (5%). There continues to be an under treatment of fever in patients with TBI by critical care nurses despite our knowledge of its negative effects on outcomes. There remains a gap in translation between patient outcomes research and bedside practice that needs to be overcome, thus research efforts need to now focus on understanding nurses' decision-making processes and the best methods of fever reduction in patients with TBI.

Adult↗
PubMed2006

Nurse executive and staff nurse perceptions of the effects of reorganization in Veterans Health Administration hospitals.

OBJECTIVE: To examine nurse executive perceptions of effects of service line reorganization on nurse executive roles, nursing staff and patient care, and compare nurse executive responses to staff nurse reports of job satisfaction and quality of care in the same types of Veterans Health Administration facilities. BACKGROUND: Although a growing body of research focuses on the association between nurse staffing structures, nurse satisfaction, and patient outcomes, relatively little attention has been paid to the effects of hospital restructuring on nursing management and nursing staff. METHODS: Data on hospital and nursing service organization and nurse executive perceptions were collected through structured interviews with 125 nurse executives conducted from December 2002 through May 2003. Staff nurse data were derived from a survey of Veterans Health Administration nursing staff conducted from February through June 2003 at the same facilities. RESULTS: Nurse executives in Veterans Health Administration described significant changes in the nurse executive role, and new challenges for managing nursing practice and achieving consistent quality of nursing care. Although nursing management perceived differences in the overall effects of restructuring on nursing staff depending on the type of reorganization, staff nurses reported significant differences in perceived quality of patient care across organization types.

Attitude of Health Personnel↗
PubMed2006

Working across the boundaries of health professions disciplines in education, research, and service: the University of Washington experience.

The Institute of Medicine's vision for health professions education specifies working together across professions and schools to provide patient-centered care. Improvement in collaborative preparation of health professionals is seen as central to achieving substantial improvement in the quality of health care. In this article, the authors address one central question: How can medical schools work with other health-sciences schools to promote their educational, research, and service missions? The authors summarize the history of the University of Washington (UW) Health Sciences Center in promoting interprofessional collaboration in education, service and research; analyze the key strategic, structural, cultural and technical elements that have promoted success or served as barriers in the development of the UW Center for Health Sciences Interprofessional Education and Research; and suggest strategies that may be transferable to other institutions seeking to implement an interprofessional health sciences program. These include both top-down and bottom-up authority and function in key working groups, institutional policies such as interprofessional course numbers and shared indirect costs, and development of a culture of interprofessionalism among faculty and students across program boundaries.

Biomedical Research↗
PubMed2006

Intensive care unit quality improvement: a "how-to" guide for the interdisciplinary team.

OBJECTIVE: Quality improvement is an important activity for all members of the interdisciplinary critical care team. Although an increasing number of resources are available to guide clinicians, quality improvement activities can be overwhelming. Therefore, the Society of Critical Care Medicine charged this Outcomes Task Force with creating a "how-to" guide that focuses on critical care, summarizes key concepts, and outlines a practical approach to the development, implementation, evaluation, and maintenance of an interdisciplinary quality improvement program in the intensive care unit. DATA SOURCES AND METHODS: The task force met in person twice and by conference call twice to write this document. We also conducted a literature search on "quality improvement" and "critical care or intensive care" and searched online for additional resources. DATA SYNTHESIS AND OVERVIEW: We present an overview of quality improvement in the intensive care unit setting and then describe the following steps for initiating or improving an interdisciplinary critical care quality improvement program: a) identify local motivation, support teamwork, and develop strong leadership; b) prioritize potential projects and choose the first target; c) operationalize the measures, build support for the project, and develop a business plan; d) perform an environmental scan to better understand the problem, potential barriers, opportunities, and resources for the project; e) create a data collection system that accurately measures baseline performance and future improvements; f) create a data reporting system that allows clinicians and others to understand the problem; g) introduce effective strategies to change clinician behavior. In addition, we identify four steps for evaluating and maintaining this program: a) determine whether the target is changing with periodic data collection; b) modify behavior change strategies to improve or sustain improvements; c) focus on interdisciplinary collaboration; and d) develop and sustain support from the hospital leadership. We also identify a number of online resources to complement this overview. CONCLUSIONS: This Society of Critical Care Medicine Task Force report provides an overview for clinicians interested in developing or improving a quality improvement program using a step-wise approach. Success depends not only on committed interdisciplinary work that is incremental and continuous but also on strong leadership. Further research is needed to refine the methods and identify the most cost-effective means of improving the quality of health care received by critically ill patients and their families.

Advisory Committees↗
PubMed2006

Cerebrovascular dynamics with head-of-bed elevation in patients with mild or moderate vasospasm after aneurysmal subarachnoid hemorrhage.

BACKGROUND: In patients with aneurysmal subarachnoid hemorrhage, elevation of the head of the bed during vasospasm has been limited in an attempt to minimize vasospasm or its sequelae or both. Consequently, some patients have remained on bed rest for weeks. OBJECTIVES: To determine how elevations of the head of the bed of 20 degrees and 45 degrees affect cerebrovascular dynamics in adult patients with mild or moderate vasospasm after aneurysmal subarachnoid hemorrhage and to describe the response of mild or moderate vasospasm to head-of-bed elevations of 20 degrees and 45 degrees with respect to variables such as grade of subarachnoid hemorrhage and degree of vasospasm. METHODS: A within-patient repeated-measures design was used. The head of the bed was positioned in the sequence of 0 degrees -20 degrees -45 degrees -0 degrees in 20 patients with mild or moderate vasospasm between days 3 and 14 after aneurysmal subarachnoid hemorrhage. Continuous transcranial Doppler recordings were obtained for 2 to 5 minutes after allowing approximately 2 minutes for stabilization in each position. RESULTS: No patterns or trends indicated that having the head of the bed elevated increases vasospasm. As a group, there were no significant differences within patients at the different positions of the head of the bed. Utilizing repeated-measures analysis of variance, P values ranged from .34 to .97, well beyond .05. No neurological deterioration occurred. CONCLUSIONS: In general, elevation of the head of the bed did not cause harmful changes in cerebral blood flow related to vasospasm.

Adolescent↗
PubMed2006

Effect of continuous display of cerebral perfusion pressure on outcomes in patients with traumatic brain injury.

BACKGROUND: Clinical bedside monitoring systems do not provide prominent displays of data on cerebral perfusion pressure (CPP). Immediate visual feedback would allow more rapid intervention to prevent or minimize suboptimal pressures. OBJECTIVE: To evaluate the effect of a highly visible CPP display on immediate and long-term functional outcome in patients with traumatic brain injury. METHODS: A total of 157 patients with traumatic brain injury at a level 1 trauma center who had invasive arterial blood pressure and intracranial pressure monitoring were randomized to beds with or without an additional, prominent continuous CPP display. Primary end points were scores on the Extended Glasgow Outcome Scale (GOSE) and Functional Status Examination (FSE) 6 months after injury. Secondary end points were GOSE scores at discharge and 3 months after injury and FSE score 3 months after injury. RESULTS: Although GOSE and FSE scores at 6 months were better in the group with the highly visible CPP display, the differences were not significant. Slope of recovery for GOSE and FSE over all follow-up time points did not differ significantly between groups. However, the intervention's positive effect on odds of survival at hospital discharge was strong and significant. Within a subgroup of more severely injured patients, the intervention group was much less likely than the control group to have CPP deviations. CONCLUSIONS: The presence of a highly visible display of CPP was associated with significantly better odds of survival and overall condition at discharge.

Adult↗
PubMed2004

Framing the problem of measuring and improving healthcare quality: has the Quality Health Outcomes Model been useful?

OBJECTIVE: The objective of this study was to determine the uses of the Quality Health Outcomes framework and indicator categories in the healthcare literature. DATA SOURCES: We studied personal communications and conducted a literature search using computerized databases since 1997, when the recommendations of the Invitational Conference on Measures and Outcomes of Care Delivery were available. PRINCIPAL FINDINGS: The Quality Health Outcomes Model has been used explicitly to frame a small number of research summaries and programs. The outcome indicator categories can be found in several "report card" initiatives in the United States and Canada. Use of these outcome categories, thought to be sensitive to nursing care inputs, has grown since 1977, with a rising number of uses linked to system or organizational factors or interventions. CONCLUSIONS: This model and others like it are increasingly forming the conceptual framework for studies that evaluate quality and system interventions to improve care. However, the available data continue to require the linking of negative outcomes (adverse events, complications) to structural and process inputs that reflect nursing care. An urgent need remains to incorporate this broader range of outcomes into available databases.

Canada↗
PubMed2004

A theory-driven approach to evaluating quality of nursing care.

PURPOSE: To review the propositions of a theory-driven approach and to discuss its application to evaluating the quality of nursing care. ORGANIZING FRAMEWORK: The focus in the theory-driven approach to evaluation is on identifying patient, professional, and setting characteristics that affect the processes of care at micro and meso levels, which in turn contribute to outcome achievement. Implications for examining the interrelationships among characteristics, processes, and outcomes are discussed and illustrated with examples from published research. CONCLUSIONS: Determining how these variables influence each other provides a valid and comprehensive understanding of the contribution of nursing within the health care system.

Humans↗
PubMed2004

Is there a sex difference in the course following traumatic brain injury?

Traumatic brain injury (TBI) is a significant cause of death and disability in the United States. Sex has not been thoroughly examined as a factor that may influence outcome following TBI. Clinical studies involving humans that have focused on sex and TBI outcome have yielded inconclusive results, yet sex-related physiologic differences have been demonstrated in animal studies. The purpose of this study is to examine the interaction of sex and age in relation to outcome at 3 and 6 months postinjury in a population of individuals with TBI. The sample includes 157 subjects (124 males, 33 females), 16 to 89 years of age, admitted to a level 1 trauma center following TBI. Physiologic data and information about injury severity and clinical course were gathered during hospitalization. Outcome was assessed at 3 and 6 months postinjury using the Extended Glasgow Outcome Scale (GOSE) and Functional Status Examination (FSE). In this sample, there was a significant relationship between sex and age with respect to functional outcome at 6 months following TBI, controlling for initial injury severity. Females age 30 years or older had significantly poorer outcome as measured by the GOSE (P = 0.031) and the FSE (P = 0.037) than either males or younger females. There was also a very different rate of recovery, with women age 30 years and older, on average, showing no improvement between 3 and 6 months postinjury. Further study is needed to elucidate the reasons why sex may affect outcome following TBI.

Adolescent↗
PubMed2003

Health systems' accountability for patient safety.

Patient safety experts, including the Institute of Medicine Committee on Quality of Health Care in America, have emphasized the need to focus on systems failure as the source of most error in health care. This requires an emphasis on prevention and on health systems' accountability for error. This article discusses traditional and evolving approaches to systems' accountability for error. While there are some significant recent developments, such as the JCAHO new Patient Safety Goals, many issues remain about how to determine and enforce systems' accountability for error. These include identifying what systems will be held accountable for and how accountability will be enforced. While reporting of errors is one route toward accountability, many questions remain regarding the most effective approach toward error reporting. Research on and evaluation of reporting systems and other approaches toward systems' accountability will be important in moving forward in this area.

Accreditation↗
PubMed2002

The impact of aneurysmal subarachnoid hemorrhage on functional outcome.

Despite advances in the management of aneurysmal subarachnoid hemorrhage (SAH), a significant percentage of survivors are left with persistent cognitive, behavioral, and emotional changes that affect their day-to-day lives. This article describes outcome at 3 months after aneurysmal SAH in 61 patients, using the Extended Glasgow Outcome Scale (GOSE) and the Functional Status Examination (FSE). The GOSE provides a measure of overall functional outcome but does not address the specifics of functional limitations. The FSE, in addition to identifying functional limitations, provides insight into factors contributing to them and the extent to which SAH survivors perceive them as affecting their day-to-day activities. The findings of this study demonstrate that SAH survivors have considerable limitations in functional status in almost all areas of daily living at 3 months following SAH. The limitations were attributed to a variety of physical, cognitive, and emotional factors, and they were reported to be moderately to severely bothersome in almost half of the individuals. The findings highlight the need for appropriate rehabilitation, education, and support for SAH survivors and their families to enhance coping and improve quality of life, given the substantial and persistent impact of SAH.

Adult↗
PubMed2002

Patients, nurses, and physicians have differing views of quality of critical care.

PURPOSE: To compare patient, nurse, and physician assessments of quality of care and patient satisfaction in selected critical care units. DESIGN: As part of a study of patient outcomes from critical care, data were collected between December 1991 and March 1993 from 489 patients, 518 nurses, and 515 physicians in 25 critical care units located in 14 hospitals in the U.S. Pacific Northwest. METHODS: Views of patient satisfaction and quality of care were measured using standardized instruments. All data were aggregated to the unit level (N = 25) and were normalized to a common scale for analysis. FINDINGS: Physicians rated quality of care higher than did either patients or nurses within the same critical care unit, and nurses had the lowest perceptions of quality. Nurses and patients had similar views of patient satisfaction, but physicians tended to overestimate patients' satisfaction. However, physicians', nurses', and patients' scores varied considerably within and between units. Physicians' and nurses' views of quality and patient satisfaction were strongly related to processes such as MD-RN collaboration and outcomes such as nurses' job satisfaction. CONCLUSIONS: Patients, nurses, and physicians viewed quality of care and patient satisfaction differently. Nurses' and physicians' perspectives were more related to their views of the work environment than to organizational factors, patient characteristics, or commonly used outcome measures.

Attitude↗