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PubMed1992

From one to another.

Organ transplantation is now well established as an excellent treatment for many previously fatal diseases of vital organs. For an organ to be of use to the recipient the cells must be alive but apart from kidney and hepatic lobe donation from a close blood relative, organs are removed from dead patients. The cause of death is usually a head injury or intracerebral bleed with permanent and complete destruction of the brain stem. Thus organ donation to save a life is usually associated with a tragedy for the donors and their families.

Humans↗
PubMed1985

The comprehensive burn unit.

A burn unit is only as good as its staff. Trained, experienced nurses, therapists and surgeons accustomed to dealing with large open wounds are a major requisite for the care of burned patients, who have a multisystem disease. Equipment needs include monitors, hydrotherapy tank, ready access to the operating room and comprehensive rehabilitation facilities. Skilled anesthesia, consultative support in nephrology, respirology, pediatrics and infectious diseases, a blood bank, access to human allograft and good microbiology support are necessary. Ventilatory support for associated smoke inhalation injury may be provided on the unit or in a separate ventilatory intensive care unit with isolation capability. In 1982, 29.9 Canadians per 100 000 were hospitalized for burn care (approximately 20% to 25% in burn units). Burn care requires a high staff-to-patient ratio and a hospital budget to support this is mandatory.

Burn Units↗
PubMed1998

Impact of a clinical pathway for radical retropubic prostatectomy.

OBJECTIVES: Cost containment has become an important issue in medical practice. With the implementation of collaborative care programs and critical pathways, substantial reduction in overall costs can be achieved while maintaining the quality of care and patient satisfaction. METHODS: Our series consists of 856 consecutive patients treated with radical retropubic prostatectomy by 24 surgeons in a single hospital between January 1, 1994, and January 31, 1997. A clinical pathway for radical retropubic prostatectomy was implemented July 1, 1994. The patients were subdivided into three groups: (1) baseline: patients who underwent surgery in the 6 months immediately before the pathway onset (n = 113); (2) nonpathway: 75 patients treated off the clinical pathway; and (3) pathway: 668 men placed on the clinical pathway. We compare average length of stay and average hospital charges among the three groups. We also compare average length of stay among physician volume groups: high volume physicians performed at least 12 operations per year; low volume physicians performed less than 12 operations per year. Charges were further broken down by department. Patient satisfaction was recorded by an outside source after discharge. Postoperative complications were assessed in the clinical pathway and nonpathway groups. RESULTS: Average hospital charges and average length of stay were $12,926 and 5.8 days for baseline patients, $11,795 and 5.0 days for nonpathway patients, and $10,042 and 4.0 days for pathway patients, respectively. Implementation of the clinical pathway was associated with lower charges and length of stay in the pathway group as well as the nonpathway group, with larger reductions in pathway patients. With continuous reassessment and modification of the clinical pathway, both average hospital charges and average length of stay have progressively decreased from $10,540 and 4.9 days in 1994 to $8766 and 2.7 days in January 1997. Charges were uniformly reduced in radiology, laboratory, pharmacy, operating room, anesthesia, and nursing or routine care. Patient satisfaction was similar in the pathway group and the nonpathway group. Incidence of postoperative complications did not differ significantly between the pathway and nonpathway groups. Length of stay and hospital charges were significantly lower for high than low volume surgeons, irrespective of the declines observed over time (P = 0.0001 and 0.0001, respectively). CONCLUSIONS: Average hospital charges and average length of stay for all surgeons were lowered significantly with the implementation of a clinical pathway and continue to decrease with continuous reassessment. The pathway was not associated with any increase in postoperative complications or patient dissatisfaction. Surgeons who operate frequently have lower average lengths of stay and hospital charges than those who operate infrequently.

Adult↗
PubMed1992

Pulmonary autograft. An aortic valve replacement alternative.

In selected patients, the pulmonary autograft procedure utilizing cryopreserved homografts for reconstruction of the right ventricular outflow tract is becoming an increasingly popular aortic valve replacement alternative. Longitudinal statistical reports show that patients need reoperation less often with this procedure. Because the valve is autogenous tissue, all indications to date show that the valve continues to function for extended periods of time in all patients and can accommodate growth in children. At the same time, transfer of the pulmonary valve to the aortic position provides a natural valvular flow pattern and freedom from the degenerative changes associated with bioprosthetic valves or the need for anticoagulation associated with mechanical valves.

Aortic Valve↗
PubMedDate not supplied

Admission surgery: the patient with abdominal and thoracic trauma.

1. Epidemiology may affect admission. It is essential to know what types of trauma patients are typically admitted, at what time of day, and on which day of the week. Within trauma systems, one of the major determinants of patient survival is the adequacy of surgical personnel and equipment resources. 2. Assessment of the abdominal and thoracic trauma patient is an active process, requiring constant curious attention. Due to the time-critical nature of these injuries, effective communication is paramount. There may be little or no documentation, and minimal verbal report, consisting of mechanism of injury and vital signs. A stable patient may rapidly deteriorate. 3. Injury severity and location are key in patients' mortality and morbidity. Outcomes for vascular injury surgeries depend on time lag, differences in surgeons' experience, associated injury, site of wounds, type of arterial lesions, and infection.

Abdominal Injuries↗
PubMed1994

Ethical dilemmas of do-not-resuscitate orders in surgery.

One of the most troublesome ethical dilemmas that perioperative nurses face is do-not-resuscitate (DNR) orders for surgical patients. The principles of futility, informed consent, autonomy, and beneficence underpin ethical decision making about DNR orders in surgical patients.

Adult↗
PubMed2001

Home laundering of soiled surgical scrubs: surgical site infections and the home environment.

An increasing number of hospitals have implemented programs that permit their operating room (OR) personnel to launder their soiled "scrubs" at home. Not only have they not experienced an increase in the incidence of surgical site infections (SSIs), but they have also found the policy to be financially rewarding. Whereas the Association of periOperative Registered Nurses (AORN) opposes the practice, the Centers for Disease Control and Prevention (CDC) describes it as an unresolved issue. The variances in the positions taken by these two organizations obviously accounts for the differences in positions taken by the infection control community. In the absence of any evidence in the literature, the only alternative is to draw from knowledge and experience to determine whether the practice can be considered clinically effective and does not have a harmful effect on the home environment. On the basis of the results of that examination, it is concluded that the need for having soiled scrubs laundered by a facility-approved laundry is indefensible and simply predicated on the "that's the way we've always done it" syndrome.

Costs and Cost Analysis↗
PubMed2000

Assessing the impact of total quality management and organizational culture on multiple outcomes of care for coronary artery bypass graft surgery patients.

OBJECTIVES: To assess the impact of total quality management (TQM) and organizational culture on a comprehensive set of endpoints of care for coronary artery bypass graft surgery (CABG) patients, including risk-adjusted adverse outcomes, clinical efficiency, patient satisfaction, functional health status, and cost of care. METHODS: Prospective cohort study of 3,045 eligible CABG patients from 16 hospitals using risk-adjusted clinical outcomes, functional health status, patient satisfaction, and cost measures. Implementation of TQM was measured by a previously validated instrument based on the Baldridge national quality award criteria. Organizational culture was measured by a previously validated 20-item instrument. Generalized estimating equations were used to control for potential selection bias, repeated measures, and intraclass correlation. RESULTS: A 2- to 4-fold difference in all major clinical CABG care endpoints was observed among the 16 hospitals, but little of this variation was associated with TQM or organizational culture. Patients receiving CABG from hospitals with high TQM scores were more satisfied with their nursing care (P = 0.005) but were more likely to have lengths of stay >10 days (P = 0.0003). A supportive group culture was associated with shorter postoperative intubation times (P = 0.01) but longer operating room times (P = 0.004). A supportive group culture was also associated with higher patient physical (P = 0.005) and mental (P = 0.01) functional health status scores 6 months after CABG. CONCLUSIONS: There was little effect of TQM and organizational culture on multiple endpoints of care for CABG patients. There is a need to examine further the relationships among individual professional skills and motivations, group and microsystem team processes, specifically tailored interventions, and organization-wide culture, decision support processes, and incentives. Assessing the impact of such multifaceted approaches is an important area for further research.

Adult↗
PubMed1990

The role of the professional nurse in a bone marrow transplantation programme.

Two different methods of transplantation are available. The allogeneic procedure is the transfer of bone marrow between compatible siblings, whereas in autografting the patient's own haematopoietic stem cells are collected, stored, and subsequently reinfused. Both forms have become established in the treatment of the leukaemias, aplastic anaemia, the malignant lymphomas, myeloma and certain immunologic diseases. Similarly, these techniques are being used in solid tumour oncology to reconstitute bone marrow function after high doses of chemotherapy, which would otherwise result in irreversible myelotoxicity. The success of such programmes depends upon a well developed multidisciplinary approach, prominently involving experienced and dedicated nursing staff. The latter individuals will establish contact with the patient typically during the first admission for chemotherapy and this will be consolidated during subsequent outpatient visits. Then follows the highly specialised care of central venous lines and management of radiation or chemotherapy-related side effects, often with intensive care needed for safe reversal of sepsis that may, however, be associated with renal or cardiorespiratory dysfunction. Most importantly, and again centrally involving the professional nurse, is responsibility for all aspects of maintaining and operating the protected environment, together with laminar air-flow rooms. Additional interaction is also necessary with dieticians, social workers, liaison psychiatrists, occupational therapists and frequently the infectious disease, cardiovascular, respiratory and renal services. Furthermore, achievement of optimal results presupposes the availability of a dedicated cell support section, as well as the competence to cryopreserve haematopoietic stem cells and monitor the safety of this step with in vitro bone marrow culture--another role for the specialised or academic nurse.(ABSTRACT TRUNCATED AT 250 WORDS)

Bone Transplantation↗
PubMed1978

[Analyses of space available in homes and day centers for the aged, as well as nursing homes for elderly people, in the FRG. Booking and occupation rate in homes and nursing homes for the aged (author's transl)].

Further intention of the survey having been conducted to show the consequences of the "Heimmindestverordnung" (draft dated Nov. 1974) was to obtain a review of the density of occupancy related to housing for the elderly. In homes for the old the rate of one-bed-rooms significantly increased during the last 15 years, whereas the respective quota for rooms with two, three, or more beds showed a decreasing tendency. In nursing homes density also decreased: the rate of one- and two-bed-rooms increased and the respective frequency of rooms equipped with four and more beds decreased from 55% to 13%. Regarding the density of occupancy also the other data collected such as related to variables as association the investigation-unit belongs to, commencement of operation, federal state, size of community led to some striking findings.

Aged↗
PubMed2004

Fast-tracking (bypassing the PACU) does not reduce nursing workload after ambulatory surgery.

BACKGROUND: Postoperative day-case patients are usually allowed to recover from anaesthesia in a postanaesthesia care unit (PACU) before transfer back to the day surgical unit (DSU). Bypassing the PACU can decrease recovery time after day surgery. Cost savings may result from a reduced nursing workload associated with the decreased recovery time. This study was designed to evaluate the effects of bypassing the PACU on patient recovery time and nursing workload and costs. METHODS: Two hundred and seven consenting outpatients undergoing day surgery procedures were enrolled. Anaesthesia was induced and maintained with a standardized technique and the electroencephalographic bispectral index was monitored and maintained at 40-60 during anaesthetic maintenance. At the end of surgery, patients were randomly assigned to either a routine or fast-tracking (FT) group. Patients in the FT group were transferred from the operating room to the DSU (i.e. bypassing the PACU) if they achieved the FT criteria. All other patients were transferred to the PACU and then to the DSU. Nursing workload was evaluated using a patient care hour chart based on the type and frequency of nursing interventions in the PACU and DSU. A cost associated with the nursing workload was calculated. RESULTS: The overall time from end of anaesthesia to discharge home was significantly decreased in the fast-tracking group. However, overall patient care hours and costs were similar in the two recovery groups. CONCLUSION: Bypassing the PACU after these short outpatient procedures significantly decreases recovery time without compromising patient satisfaction. However, the overall nursing workload and the associated cost were not significantly affected.

Adolescent↗
PubMed1985

Isolation practices: a historical perspective.

Isolation practices assume a major role in the activities of many hospital infection prevention and control programs, yet few of the practices have been studied for efficacy. The origins for some of these practices can be traced to the nursing literature published in the American Journal of Nursing in the early part of the century. Others originated with public health measures for quarantine of communicable diseases in the community or attempts to simulate operating room practices for compromised patients. This historical review presents information about isolation practices from the perspective of the American Journal of Nursing with additional information from some Centers for Disease Control and American Hospital Association publications. The American Journal of Nursing was selected because it is a major source for content of nursing textbooks from which most nurses first learn isolation practices. Nurses are also the persons primarily responsible for the implementation of isolation practices in hospitals. Two themes emerged from this historical review: (1) a continuing debate about the importance of the inanimate environment and the importance of the airborne route versus the importance of contact with moist body substances as major modes of transmission of infectious agents and (2) a continuing debate between those who believe in special isolation techniques only for persons with diagnosed infections and those who believe all persons may harbor potentially infectious agents and who therefore focus attention on assessment of care requirements where contact with body substances is anticipated. This review is intended to encourage critical evaluation of isolation practices in use in hospitals today.

Cross Infection↗
PubMedDate not supplied

Entry level: associate degree--are we ready?

We need to look at the educational preparation of the surgical technologist and consider the move to a single entry level, the associate degree. There are reasons to support the community college associate degree program. Cost effectiveness, integration into the main stream of allied health education, access to experts in their fields, controlled laboratory and clinical experience, transferability, and upward mobility are just a few. Let us learn from the problems of multiple entry that now plague nursing education. We are young enough not to have become entrenched. Let us declare a single entry, associate degree level now.

Hospitals↗
PubMed1988

Complications of endotracheal intubation.

Tracheal intubation for airway control, once done only by anesthesiologists during surgical procedures, is now being done by physicians in other specialties and by nurses, technicians, and paramedics in areas other than the operating room. Intubation, however, does not always assure a patent airway. Unrecognized esophageal placement of endotracheal tubes is the major cause of cardiac arrest and brain damage associated with intubation. Though auscultation for breath sounds is the universally accepted method of verifying proper tube placement, recent studies indicate that it is reliable only approximately two thirds of the time in situations in which verification of proper placement is needed most and is least obvious. The usefulness of this technique merits reassessment. Identification of carbon dioxide in end-expired air is the most reliable method for verification, but instruments to detect carbon dioxide are usually immediately available only in special care and surgical suites. Mouth-to-tube insufflation with a two-way disposable microbial filter differentiates immediately between esophageal and tracheal placement and can be used in any area. Malpositioned and malfunctioning tubes cause partial or complete obstruction accompanied by varying degrees of hypoxemia and hypercapnia. Respiratory and circulatory derangements and brain damage ensue if the problem is not promptly recognized and corrected. We discuss the most common causes of tube malfunction.

Airway Obstruction↗
PubMedDate not supplied

Brave new world.

This week's National Association of Theatre Nurses' annual congress will be an opportunity to explore how the changes in theatre nursing reflect wider changes in nursing generally.

Humans↗
PubMed1988

An acupuncture-associated outbreak of hepatitis B in Jerusalem.

Two clusters of between five and eleven cases of hepatitis B associated with acupuncture treatment by a physician occurred in Jerusalem in late 1986. The origin of the outbreak is believed to have been an Ethiopian immigrant surgical patient, a known HBsAg carrier, who infected an operating room nurse during a surgical procedure. This is the first recorded instance of transmission of HBV from an Ethiopian immigrant to the local Israeli population. We reiterate the need for the enforcement of correct sterilization techniques in all skin-piercing settings, a step which in many countries will require the licensing of a variety of occupations not presently covered by health regulations.

Acupuncture Therapy↗