1. Chu, Julie J. MSN, CRNP

Article Content


An intervention involving family and facility staff yields improvements.

Family members providing care to nursing home residents with dementia have a more favorable perception of the experience and of their relationship to staff members after participating in a family-oriented intervention.


After 14 Midwestern U.S. nursing homes with special units for residents with dementia were paired according to type of ownership (private, private nonprofit, or public) and unit size, one of each pair was randomly assigned to receive the Family Involvement in Care (FIC) intervention while the other served as control. The intervention entailed orientation of the primary family caregiver (and of other family members, if desired) to the facility, the special unit, and the partnership role; education in the provision of care; negotiation of a care partnership agreement between the family member and the staff (specifying how much of it the family member wants to provide, for example); and subsequent evaluation and possible renegotiation of the arrangement. One hundred eighty-five family members (average age, 61 years; 94% white; 75% women) and 845 staff members (average age, 37 years; 93% white; 92% women; 13% registered nurses) participated in the study. In the nine-month period during which the FIC intervention was conducted, the outcomes among family members were measured five times (including at baseline) with the Family Perceptions of Care-giving Role instrument and the Family Perceptions of Care Tool, and outcomes among the staff members were determined using the Staff Perceptions of Caregiving Role, the Attitudes Toward Families Checklist, and the Caregiver Stress Inventory, which were administered at baseline and every six months during the two-year study period. All of the tools had been developed and tested by the investigators.


The results showed that the FIC intervention improved family members' perceptions of the role of the caregiver, of their relationship with staff members, and of the care provided to their relatives; ameliorated their feelings of both loss and captivity and the sense of being disregarded by the staff; prevented the decline in satisfaction with the residents' activities among their contemporaries (usually spouses); and increased satisfaction with the care provided. Staff members' perceptions of the role of family caregiver, particularly in regard to the three scale categories ("dominion," "disruption by family members," and the "irrelevance of family") also improved.


Although further studies using more heterogenous samples and with more frequent follow-up are warranted, this one suggests that this type of family-oriented intervention, especially with stronger leadership from registered nurses in family involvement, could improve the perceptions of both family and staff members of family involvement in the care provided to nursing home residents with dementia.


Maas ML, et al. Nurs Res 2004;53(2):76-86.



The mortality rate associated with metabolic syndrome is lower.

Being physically fit lowers the all-cause and cardiovascular disease-related mortality rates in both healthy men and those with metabolic syndrome, according to a recent study.


In a large study, 19,223 men in the Aerobics Center Longitudinal Study (80.5% healthy [n = 14,028 fit; n = 1,438 unfit] and 19.5% with metabolic syndrome [n = 2,494 fit; n = 1,263 unfit]) were followed from 1979 until death or through 1996 to determine the mortality rates and the extent to which level of cardiorespiratory fitness affected them. The participants (mean age, 43.1 years) did not have histories of coronary heart disease, stroke, or cancer at baseline. They underwent various laboratory assays to determine the presence of metabolic syndrome and performed a treadmill exercise test until the point of exhaustion to determine the level of cardiorespiratory fitness.


During 196,223 person-years of follow-up, 480 deaths occurred, 161 of which were attributable to cardiovascular disease. Risk of death by any cause and from cardiovascular disease was 1.29 times and 1.89 times higher, respectively, among men with metabolic syndrome compared with healthy men, probabilities that decreased after adjustment for levels of cardio-respiratory fitness. After that adjustment, unfit healthy men were 2.18 times more likely to die of any cause, compared with fit men, while unfit men with metabolic syndrome were 2.01 times more likely to die of any cause, compared with fit men with metabolic syndrome. Those rates increased to 3.21 times and 2.25 times more likely, respectively, in death attributable to cardiovascular disease. The reduction in mortality rate among men with metabolic syndrome was proportional to the level of cardiorespiratory fitness. Obesity didn't necessarily increase the mortality rate in men otherwise physically fit.


Placing emphasis on the importance of cardiorespiratory fitness and encouraging patients, particularly those with metabolic syndrome, to attain and maintain it as part of disease management appear to be crucial.


Katzmarzyk PT, et al. Arch Intern Med 2004;164(10):1092-7.



Timing may be crucial for some.

Hip fracture surgery performed early, that is, within 24 hours of injury, is associated with less pain and shorter length of hospital stay in some patients, but not with either lower mortality rate or improved function, according to a recent study.


In the prospective, cohort study, 1,206 patients with hip fracture admitted consecutively to four New York City hospitals during a period of 29 months were followed to determine the association between the timing of hip fracture surgery and outcomes such as function, mortality, pain, and length of stay. Eligible patients included those 50 years of age or older with a unilateral hip fracture that occurred outside the hospital and that wasn't the result of multiple trauma or a pathologic process, in the absence of prior fracture at the same site. Using the Functional Independence Measure, the researchers questioned patients about their functional status prior to fracture, and also assessed their pain levels during the first five days of hospitalization and documented any complications during hospitalization. Follow-up was conducted six months later by telephone for the purpose of obtaining functional status and mortality data.


Of the 1,178 patients who underwent hip fracture surgery, only one third did within 24 hours of injury. Although surgery within that period wasn't associated with a lower mortality rate or greater mobility at the point of follow-up, patients who had fewer days of severe pain during the first five days of hospitalization spent less time in the hospital, compared with those who had surgery performed after 24 hours. There were no significant differences between the two groups in postoperative pain levels and postoperative lengths of hospital stay.


More patients with hip fracture might be able to undergo surgery sooner if prohibitive circumstances in the hospital system were effectively addressed, and nurses, in particular, can help to make operating rooms available more quickly by scheduling surgical procedures appropriately, so that the flow of patients throughout the operating suite is improved.


Orosz GM, et al. JAMA 2004;291(14): 1738-43.



In children, its efficacy may vary.

Interactive music therapy doesn't significantly reduce preoperative anxiety in children undergoing general anesthesia and surgery, compared with standard care.


Researchers randomly assigned 123 consecutive children, ages three to seven years, who were to undergo elective outpatient surgery and general anesthesia, to receive interactive music therapy (n = 51), oral midazolam (versed) (n = 34), or standard care (as control) (n= 38). Therapy was initiated in the holding area and continued until anesthesia induction for as long as 30 minutes. Unless the patients were extremely anxious before entering the operating room (OR), only the music therapist accompanied them into it. Patients in the midazolam group received 0.5 mg/kg PO (as much as 20 mg) 30 minutes prior to surgery. While in the holding area and until induction of anesthesia, patients were recorded on videotape so that assessors blinded to the details of the study could evaluate their levels of anxiety. Anxiety was measured with the Yale Preoperative Anxiety Scale; patients' compliance with anesthesia induction with the Induction Compliance Checklist, temperament with the Emotionality, Activity, Sociability, and Impulsivity Scale; and self-reported anxiety with the State-Trait Anxiety Inventory.


Anxiety levels within the group of children that received music therapy differed significantly upon separation from parents and entrance into the OR (but not upon introduction of the anesthesia mask), depending on which of the two music therapists worked with them. In general, those in the midazolam group were much less anxious during induction of anesthesia compared with patients in the music therapy and control groups (between which anxiety levels weren't significantly different), even after controlling for the effects of the different therapists.


Music therapy, therefore, may be useful in reducing anxiety in some preoperative patient groups and in other medical settings, but the authors express serious doubt that its use in the pediatric pre-operative setting is warranted.


Kain ZN, et al. Anesth Analg 2004;98(5): 1260-6, table of contents.



Is a computer-based reminder system effective?

The use of a computer-based decision-analysis reminder system, by which surgeons are alerted, preoperatively, to surgical patients who are at great risk of deep vein thrombosis (DVT) and appropriate preventive care is provided (as recommended in the American College of Chest Physicians guidelines) was shown in a recently published study to significantly increase the prophylaxis rate but not diminish the incidence of postoperative symptomatic venous thromboembolism if the baseline prophylaxis rate was high already.


Researchers at a single hospital compared the 90-day combined postoperative rates of symptomatic, confirmed DVT, pulmonary embolism (PE), and PE-related death in a preintervention group (in a study conducted in 1997) (n = 2,077) and a postintervention group (in one conducted in 1998) (n = 2,093). A decision-analysis computer program searched the records of patients three times daily to identify those who were scheduled to undergo one of 224 surgical procedures that would necessitate DVT prophylaxis. The appropriate records were distinguished with the letters "DVT" to remind clinicians to provide patients with anticoagulants, if appropriate, or sequential pneumatic compression devices, to be applied from the time of anesthesia to postoperative ambulation.


The prophylaxis rate prior to the intervention, which was high already at 89.9%, increased to 95% afterward, the increase being the greatest among those who underwent general surgical procedures and gynecologic surgical procedures. But despite the increases, there wasn't any overall beneficial effect on clinical outcomes--46 patients developed symptomatic venous thromboembolisms postoperatively, and the percentage that developed them didn't differ significantly between the preintervention and postintervention groups, 1% and 1.2%, respectively. Moreover, most of the patients had received at least one of the recommended methods of prophylaxis.


Although using a reminder system wasn't found to be helpful in reducing the number of poor clinical outcomes in the population in this study, it has been shown to improve outcomes in studies conducted in other surgical settings in which prophylaxis rates remain low. Additionally, further research investigating strategies other than anticoagulation or the use of sequential pneumatic compression devices that may be effective in the prevention of thromboembolism may be necessary.


Mosen D, et al. Chest 2004;125(5):1635-41.



Several nonpharmacologic interventions may be effective in infants.

The most common method of testing blood in infants, the heel stick, is controversial. There is much evidence that the procedure is extremely painful; the short-term effects of such pain are irrefutable, and long-term effects are likely. Reducing pain from heel sticks has been a goal of providers for years. To this end, researchers in Thailand performed a small metaanalysis of four studies of preterm and full-term infants conducted in Thailand, and results show that swaddling, positioning, and maternal holding and touching can, to different degrees, reduce the pain response associated with heel sticks.


The studies were systematically analyzed to determine the effects of swaddling, positioning, and maternal holding and touching on heart rate and oxygen saturation levels after heel sticks. Inclusion criteria included studies in which heel sticks were performed on preterm and term infants, established methods of measurement were used (all infants had also been videotaped before, during, and after the heel sticks to determine pain scores; changes in heart rates and oxygen saturation levels had also been measured), and each infant was evaluated twice--once after being swaddled, positioned, or held or touched by the child's mother, and once in the absence of those interventions.


The effects on pain after heel sticks were significantly greater after swaddling, positioning, and maternal holding or touching than they were when the interventions were not performed, with swaddling in full-term infants producing the greatest effect. While the positioning of preterm infants was associated with moderate-to-large effect, lasting four to five minutes after the heel sticks, the effects of the other interventions diminished gradually during that same period of time. The swaddling of term infants was also associated with the greatest reduction in heart rate after heel sticks.


Because of the study's small sample size, the use of different methods of pain measurement, and other limitations, its generalizability is limited.


Prasopkittikun T, Tilokskulchai F. J Perinat Neonatal Nurs 2003;17(4):304-12.