Nursing morbidity and mortality conferences: promoting clinical excellence.
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Clinical Competence↗
Biomedical subjects
Sandra Lookinland
Publications and source records attributed to Sandra Lookinland.
Nontraditional models of care delivery: have they solved the problems?
Healthcare delivery systems in the United States are changing rapidly in response to socioeconomic forces. In the new competitive healthcare market, work has been redesigned, with hospitals changing their skill mix to include unlicensed assisitive personnel. Having previously described the more traditional models of care delivery, (JONA, June 2004), the authors will now discuss a variety of nontraditional practice models that have been developed to address the changing needs of healthcare. These models and their driving forces are described. Indicators of success, including quality, cost, and satisfaction, are also examined.
Delivery of Health Care↗
Inquiry in baccalaureate nursing education: fostering evidence-based practice.
With the increasing emphasis on evidence-based nursing practice, nurse educators need to more fully implement teaching strategies that help students gain critical thinking skills related to inquiry and understand the importance of evidence-based nursing practice. Research and scholarship emphases in one baccalaureate nursing program, student-identified benefits, and challenges associated with incorporating inquiry across the curriculum are described in this article. In clinical journal entries, students described the following benefits associated with curricular emphasis on inquiry: increased interest in evidence-based nursing practice and participating in the generation of research; enhanced critical thinking skills through the development of knowledge, experience, and competencies; increased motivation to continue professional growth and development by participating in lifelong learning; the desire to become better consumers of research findings; better understanding of the "real world" of clinical research; and increased desire to pursue graduate studies in nursing. The challenge to promote student growth toward competence in the application of evidence-based principles in clinical practice is ongoing.
Communication↗
Traditional models of care delivery: what have we learned?
Traditional models of patient care delivery include total patient care and functional, team, and primary nursing. These models differ in clinical decision making, work allocation, communication, and management, with differing social and economic forces driving the choice of model. Studies regarding quality of care, cost, and satisfaction for the models provide little evidence for determining which model of care is most effective in any given situation. Despite lack of evidence, newer models continue to be implemented. This article compares the advantages and disadvantages of models, critiques the existing studies, and offers recommendations regarding the evidence needed to make informed decisions regarding care delivery models.
Costs and Cost Analysis↗
The role of genetics in the risk of thromboembolism: prothrombin 20210A and oral contraceptive therapy.
PURPOSE: To provide an overview of the prothrombin 20210A mutation, its effects on the incidence of venous thromboembolism (VTE) in users of oral contraceptive therapy (OCT), and screening recommendations for the primary care practice setting. DATA SOURCES: Several databases, including MEDLINE, EMBASE, BIOSIS, Cochrane Library, and SciSearch, were searched for articles published between 1996 and 2003. An integrative review of studies addressing prothrombin 20210A was done using available case-series and case-control studies. No randomized controlled trials on prothrombin 20210A were available in the literature from the years searched. CONCLUSIONS: Prothrombin 20210A increases the risk of developing a VTE for those who carry the genetic mutation. The presence of either concomitant circumstantial factors (e.g., surgery or immobilization) or a combination of genetic factors (e.g., factor V Leiden and prothrombin 20210A) raises the frequency of VTEs to an even greater extent. The risk increases exponentially in users of OCT. Screening guidelines for the use of OCT in prothrombin 20210A carriers remain unclear due to the paucity of empirical evidence related to the topic. IMPLICATIONS FOR PRACTICE: Practitioners caring for a prothrombin 20210A carrier should maintain a high degree of suspicion with even vague signs or symptoms of a possible VTE. Practitioners should consider completing a full diagnostic workup for VTE on that patient, particularly if that patient is taking OCT. Until evidence becomes available as to the best anticoagulation practice after an initial or recurrent VTE in a prothrombin 20210A carrier, standard treatment guidelines for anticoagulation should be followed.
Contraceptives, Oral, Hormonal↗
Treatment of hypertriglyceridemia with omega-3 fatty acids: a systematic review.
PURPOSE: To (a) critically appraise available randomized controlled trials (RCTs) addressing the efficacy of long-chain omega-3 fatty acids as secondary agents for prevention of hypertriglyceridemia and (b) make recommendations for clinical practice. DATA SOURCES: Two independent reviewers examined all RCTs from 1994 to 2003 identified in several databases, extracted data from each study, and used the previously tested Boyack and Lookinland Methodological Quality Index (MQI) to determine study quality. CONCLUSIONS: Ten studies reported long-chain omega-3 fatty acids to be effective in the treatment of hypertriglyceridemia. The average decrease in triglycerides was 29%, total cholesterol 11.6%, very low density lipoprotein (VLDL) 30.2%, and low-density lipoprotein (LDL) 32.5%. One study found LDLs to increase by 25%. The average increase in high-density lipoprotein was 10%. The overall average MQI score was 36% (range = 26% to 54%). Many of the RCTs had serious shortcomings, including short duration, lack of a power analysis, no intention-to-treat analysis, no report of blind assessment of outcome, and lack of dietary control as a confounding variable. IMPLICATIONS FOR PRACTICE: Overall study methodology was weak. Although the evidence supporting use of long-chain omega-3 fatty acids in the secondary prevention of hypertriglyceridemia is reasonably strong, until there are larger RCTs of better methodological quality, it is not recommended that practitioners treat hypertriglyceridemia with omega-3 fatty acid supplementation in lieu of lipid-lowering medications.
Bias↗
HRT: decide based on the evidence.
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Breast Neoplasms↗
A systematic review of the effectiveness of garlic as an anti-hyperlipidemic agent.
PURPOSE: To 1) conduct a thorough search of the literature for randomized controlled trials (RCTs) addressing the efficacy of garlic as an antihyperlipidemic agent, 2) critically appraise those studies, and 3) make a recommendation for practicing health care professionals. DATA SOURCES: Two independent reviewers extracted data from the articles identified from several data bases, using the previously tested Boyack and Lookinland Methodological Quality Index (MQI) as the standard. RESULTS: Six of ten studies found garlic to be effective. The average drop in total cholesterol was 24.8 mg/dL (9.9%), LDL 15.3 mg/dL (11.4%), and triglycerides 38 mg/dL (9.9%). The overall average MQI score was 39.6% (18%-70%). Major shortcomings of many of the RCTs included short duration, lack of power analysis and intention to treat analysis, as well as lack of control of diet as a confounding variable. CONCLUSION/IMPLICATIONS: The low methodological quality of the studies make it difficult to recommend garlic as an antihyperlipidemic agent. Until larger RCTs of longer duration, which correct the existing methodological flaws, are designed and carried out, it is best not to recommend garlic be used to treat mild to moderate hyperlipidemia.
Anticholesteremic Agents↗
Factor V Leiden and venous thromboembolism: risk associated with hormone replacement therapy.
PURPOSE: To determine the risk-benefit ratio of hormone replacement therapy (HRT) and the cost-effectiveness of screening in perimenopausal and postmenopausal women who are carriers of factor V Leiden, as well as to provide evidence-based clinical recommendations for the primary care provider. DATA SOURCES: Databases searched included EMBASE, BIOSIS, MEDLINE, CINAHL, PubMed, SciSearch, and the Cochrane Database. Two reviewers extracted, reviewed, and concurred upon relevant evidence identified in the data-bases. RESULTS: Results confirmed that all women have a higher risk for the development of venous thrombosis while on HRT. The presence of a genetic mutation, such as factor V Leiden, in combination with HRT dramatically increased an individual's chance for developing venous thrombi. CONCLUSION/IMPLICATIONS: Based on the findings of the studies reviewed, it is recommended that women wishing to initiate HRT be thoroughly screened for known risk factors of thrombosis. If risk factors are identified, genetic testing for factor V Leiden may be warranted.
Activated Protein C Resistance↗
Evidence-based treatment of hypertension. JNC 7 Guidelines provide an updated framework.
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Adrenergic beta-Antagonists↗
Nurse practitioners' treatment of febrile infants in Utah: comparison to physician practice nationally.
PURPOSE: To determine nurse practitioners' (NPs') knowledge of published guidelines involving the treatment of infants with fever without a source and to compare the practice of NPs in Utah to physicians nationally. DATA SOURCES: Using a comparative descriptive design, a survey was sent to 450 NPs in Utah replicating the methodology of a 1998 survey of physicians. The NPs were asked about their evaluation decisions and management strategies for various ages of infants/toddlers with fever without a source. CONCLUSIONS: The practice decisions of NPs in Utah and physicians nationally were similar. Family NPs' clinical decisions aligned more closely with family practice medical doctors and pediatric NPs' with pediatricians. Overall, the younger the patient, the more likely were NPs to order labs and antibiotics or to hospitalize/refer to a physician. The fact that management decisions were not based upon existing protocols may account for the practice variation seen among NPs. IMPLICATIONS FOR PRACTICE: Management of a febrile infant is a common clinical scenario for the primary care provider. Although evidence-based protocols exist, the treatment of febrile infants remains controversial. Overall, NPs' evaluation and management of these infants were not shown to differ from physicians. Further studies are needed to determine why clinical guidelines are not being followed.
Age Factors↗
Efficacy of raloxifene for treatment of menopause: a systematic review.
PURPOSE: To critically appraise recent randomized controlled trials (RCT) of raloxifene and its effects on the long-term consequences of menopause. DATA SOURCES: All RCTs of greater than six months duration in post-menopausal women found in MEDLINE through July 2000. CONCLUSIONS: Raloxifene lowered lipids, but estrogen had a more beneficial effect on HDL and fibrinolytic markers. Raloxifene had a more beneficial effect on triglycerides, inflammatory and thrombogenic markers. Compared to placebo, raloxifene reduced vertebral fractures but had a similar although lesser effect on bone mineral density and markers of bone turnover than estrogen. Estrogen receptor positive breast cancer was reduced by 90% with no increase in the incidence of endometrial cancer with raloxifene. The most serious side effect of raloxifene was an increased incidence of deep vein thromboses and pulmonary emboli. IMPLICATIONS: Raloxifene has been shown to be beneficial using cardiovascular and osteoporosis end-points in studies of short duration. More RCTs of longer duration with comparisons to other traditional treatments are needed before raloxifene becomes the treatment of choice.
Aged↗
African-American nurses' attitudes toward older persons.
Based on current demographic trends, more ethnic minority nurses will be caring for older adults in acute and community settings. Although elder care is adversely affected by ageist attitudes held by some nurses, the influence of race and nursing care setting on ageist attitudes has not been adequately investigated. The aims of this study were to describe the attitudes of African-American nurses toward older adults and to compare the attitudes of ethnic minority nurses working in hospital versus community settings. Using a comparative-descriptive design, more than half of the 720 (n = 720) randomly selected members of the National Black Nurses Association (N = 2,293) completed Kogan's Attitude Toward Old People Scale. Findings from this study suggested that African-American nurses expressed positive attitudes overall. Registered nurses and nurses with master's degrees displayed the most positive attitudes, while retired nurses and less educated nurses in acute-inpatient settings demonstrated the most negative attitudes. One conclusion from these data is that education regarding characteristics and needs of older adults should be provided to nurses in all settings, with emphasis placed on nurses with less education and nurses in acute-inpatient settings.
Acute Disease↗
Evaluation of a new real-time blood continuous glucose monitoring system in pregnant women without gestational diabetes. A pilot study.
The incidence of gestational diabetes mellitus (GDM) has reached epidemic proportions in the United States, affecting 200,000 pregnant women annually. Controversies exist regarding whether the glucose levels used to diagnose GDM in pregnancy should be lowered since similar fetal complications are seen in women with GDM as well as in nondiabetic women. Although GDM has been extensively studied, the effects of the earlier stage of glucose intolerance are not well understood. The objectives of this descriptive, comparative, correlational pilot study include assessment of real-time blood glucose concentrations in women (20) with idiopathic macrosomia and/or polyhydramnios but with a normal baseline glucose screening test. This group was compared to pregnant women (20) without idiopathic macrosomia and/or polyhydromnios as confirmed by normal ultrasounds (controls). All subjects had a normal screeing test and/or a 3-hour Glucose Tolerance Test earlier in the pregnancy and wore a continuous glucose monitoring system for 72 hours. No adverse maternal complications were seen. Neonatal complications included macrosomia, shoulder dystocia, and hyperbilirubinemia. There was no significant association between real-time blood glucose levels and adverse maternal or fetal/neonatal complications. There is little evidence available regarding real-time physiologic glycemic levels in pregnant women. The findings of our pilot study provide baseline data for the design of a larger study to compare blood glucose levels and complications in euglycemic women and compare to women with those impaired glucose tolerance.
Adult↗