1. Chu, Julie J. MSN, CRNP

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Nurses prefer the disposable.

Nurses are more satisfied in bathing critically ill, bedridden patients with the disposable bath, compared with a customary basin bath, because it takes less time, costs less, and is equally effective, says a study.


In order to compare the time taken by customary basin and packaged disposable bed baths, the quality of each, microbial counts on the skin after each, nurses' satisfaction with each, and the cost of each, 40 patients (62% male; mean age, 60.7 years) in three ICUs of a single hospital were given the customary bath one day and the disposable one the next. They were observed by researchers, who timed each bath, recorded the number of washcloths and products used, obtained skin samples from the groin and umbilicus areas for microbiologic studies, questioned nurses about their preference in bath type, and calculated the costs of the two types of bath.


Although the mean bath duration was shorter and the number of bathing products used significantly fewer in the disposable bath group, compared with the customary bath group (12.8 minutes and 14.4 minutes, respectively, and 0.53 products and 2.2 products, respectively), the quality of the baths, the total bacterial counts at the groin and periumbilical sites, and the overall costs didn't differ significantly between them. Most nurses preferred giving the disposable bath.


The study indicates that the disposable bath may be the preferred means of bathing patients in comparable populations, and nurses who use it may be assured that it cleans just as effectively as the customary basin bath does.


Larson EL, et al. Am J Crit Care 2004; 13(3):235-41.



A majority prefer flexible visiting hours.

A study has revealed that critically ill patients, who benefit greatly from the visits of family members, prefer a flexible visitation policy, but opinion is divided over the question of whether unlimited visiting hours or once-daily visitation is best.


Critically ill but unintubated patients (N = 62) in the ICU (n = 31) and complex care medical unit (CCMU) (n = 31) of a large academic medical center were interviewed using the Patient's Perceptions of Visiting in the Hospital questionnaire to evaluate the perceived stressors, benefits, and outcomes of family visitation as well as their preferences. The ICU maintained a visitation policy in which nurses allowed visits at their discretion, according to their knowledge of the patient and family, but in the CCMU visitors were allowed between 1pm and 8 pm.


Patients received three to four visits (34 to 55 minutes each) daily by an average of three visitors per visit. Whereas 37% of patients preferred the flexibility of the ICU visitation policy, 35% wanted to receive visitors only once daily, half of them in the afternoon, and many not in the evening when they were trying to rest. Patients in both units also indicated that visits should be restricted when they weren't feeling well or were scheduled for a procedure.


The results of the study provide information that can be useful in the ongoing debate concerning visitation policies and practices in ICUs and CCMUs.


Gonzalez CE, et al. Am J Crit Care 2004; 13(3):194-8.



Certain mind-body-spirit therapies may improve them.

A study has revealed that certain noetic therapies, such as stress management, imagery, and touch therapy performed on patients immediately before percutaneous interventions for acute coronary syndrome decreased worry and improved mood.


One hundred fifty patients in the Monitoring and Actualization of Noetic Training pilot study (99% of whom were men of a mean age of 64 years) were randomly assigned to receive stress management, imagery, touch therapy, off-site intercessory prayer, or standard therapy (defined as the absence of systematic interaction with the designated practitioners of the former), prior to undergoing percutaneous interventions. Patients in the stress management, imagery, and touch therapy groups received therapy at the bedside, administered by 19 volunteers, 30 minutes before undergoing percutaneous interventions. Mood was measured before and after therapy.


Baseline (pretherapy) mood ratings didn't differ significantly among the groups, according to any of the scales. Stress management, imagery, and touch therapy were found to have significantly reduced worry (the only mood significantly affected) by as much as 50%, and intercessory prayer didn't have a significant effect on any of the moods assessed. Standard therapy was associated with a 16% increase in worry, as reported by patients.


Seskevich JE, et al. Nurs Res 2004;53(2): 116-21.



No difference seen when compared with routine skin care.

The risks of nosocomial bacterial sepsis (NBS) and death aren't diminished in infants of extremely low birth weight who have emollient ointment applied to the skin, compared with those who receive standard skin care (generalized local application to the site of injury), during the first two weeks of life.


Within 48 hours of birth, infants of extremely low birth weight (N = 1,191) weighing 501 g to 1,000 g and at a gestational age of 30 weeks or less were randomly assigned to receive the prophylactic ointment Aquaphor every 12 hours or routine skin care through the 14th day of life. Prescribed amounts of ointment, based on body weight of either 501 g to 750 g or 751 g to 1,000 g, were applied to the body, excepting the scalp, face, and areas of skin that were not intact. Infants in the routine skin care group were allowed the application of ointment for any skin condition for a limited period of time, and antibiotic administration was initiated in all and continued for 48 hours. The primary outcome was NBS and death by the 28th day of life.


The analysis of the infants (n = 602, prophylactic ointment group; n = 589 routine skin care group) revealed no difference in the combined primary outcome (approximately one-third in both groups); NBS alone developed in 25.8% of patients in the prophylactic ointment group (predominantly in the infants of lower birth rate [501 g to 750 g] and in the presence of infection with coagulase-negative staphylococci) and 20.4% of those in the routine skin care group-a significant difference. The skin of the patients in the prophylactic ointment group was in better condition.


Edwards WH, et al. Pediatrics 2004;113(5): 1195-203.



Age and sex may be important factors.

According to a recent study, among patients with heart failure, women younger than 65 initially reported poorer health-related quality of life, compared with men at that age and with older patients of either sex.


A convenience sample of 211 patients with heart failure at two outpatient clinics of an urban county hospital were interviewed by telephone at baseline and four, eight, and 26 weeks later about their health and the quality of their lives, using the Minnesota Living With Heart Failure Questionnaire (LHFQ) and the Chronic Heart Failure Questionnaire (CHFQ). Other information obtained included demographic data and New York Heart Association (NYHA) classification of heart failure. Patients were categorized into groups of men younger than 65 years, women younger than 65 years, men 65 or older, and women 65 or older.


Only 78% of the patients-those who completed the baseline and 26th-week interviews-were included in the analyses (mean age, 57.6 years; 52% were women [62% of women and 84% of men were younger than 65]; 61% were African American; 78% had evidence of NYHA class II or III heart failure at baseline). At baseline, the total CHFQ scores and subscale scores (dyspnea, fatigue, emotional), as well as the total LHFQ scores and one subscale score (emotional), differed significantly between the four age and sex groups, with patients younger than 65 and women, in general, having significantly lower scores in many of those categories, compared with those 65 and older. Although, overall, scores had improved significantly by the 26th week (more so in women younger than 65), men and women younger than 65 had significantly worse LHFQ total scores than older men and women had, and, overall, women had significantly worse LHFQ total scores, compared with men.


Because of the study's limitations, the results may not be generalizable to other populations, but the application of its results may help critical care nurses to better plan interventions for patients with heart failure.


Hou N, et al. Am J Crit Care 2004;13(2): 153-61.



Error linked to characteristics of patients and organizations.

According to a large national study, hospital-reported medical errors committed in the care provided to premature neonates are infrequent, but certain characteristics of patients and organizations are associated with a greater risk of their occurrence.


Using the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, in which information related to patient discharges from more than 20 U.S. community hospitals is collected, researchers analyzed the discharge of neonates during 1997 (particularly that of premature neonates weighing less than 2,500 g at birth) to determine the rate of medical errors and the characteristics associated with them. The characteristics of interest were birth weight, sex, race, type of payor (commercial, HMO, public), type of admission (emergent, urgent, elective), and length of stay. The hospital characteristics were regional location, size of bed, type of ownership (public, private, private nonprofit), and teaching status based on location (rural, urban non-teaching, urban teaching). The identification of medical errors was based on certain discharge diagnoses in the International Classification of Diseases, Ninth Revision, Clinical Modification.


Of the 66,146 premature neonates considered in the study, 824 were determined to have been subjected to medical error. Errors associated with complications of procedures were most common, such as those associated with mechanical complications of device implants and grafts. An inverse relationship between birth weight and rate of medical errors was found. Being male, of a minority group, or publicly insured, or having been an emergency admission or having a length of stay longer than expected, were associated with higher rates of error.


Although the rate of medical errors in premature neonates is lower than that found in other populations, several factors, including birth weight, sex, public insurance, and provision of care in urban centers, made the study patients more likely to be subject to them. Nurses and hospital administrators might use this study's data to identify necessary systemic changes and interventions.


Kanter DE, et al. Pediatr Crit Care Med 2004;5(2):119-23.



It may help to improve outcomes.

A new study shows that the implementation of an evidence-based nutritional-management protocol for patients in the ICU may improve the chances of receiving enteral nutrition and decrease the number of days on mechanical ventilation.


The clinical effects of the protocol were evaluated in 200 patients in the medical-surgical ICUs of two teaching hospitals whose ICU stay had been at least 48 hours and who were not expected to take nutrition orally. The protocol involved admission assessment (by physicians) of the need for nutritional support and the initiation of enteral nutrition, if indicated, especially through postpyloric feeding tubes, within 24 hours of ICU admission. One hundred patients (50 at each hospital) served as the control group during the preimplementation phase, which was followed by the one-month implementation phase, during which clinicians were instructed in the protocol. Afterward, an additional 100 patients were enrolled in the postimplementation group. Several nutritional and clinical outcomes were assessed.


Although enteral nutrition was more prevalent in the postimplementation group (78%) than in the preimplementation group (68%), a difference that became statistically significant after various adjustments, both the time to feed and caloric intake on the fourth day of nutritional support weren't significantly different between the groups. Patients in the postimplementation group were on mechanical ventilation for 9.5 fewer days than were those in the preimplementation group; although the two groups didn't differ in length of hospital stay, the risk of death was 56% lower in the postimplementation group.


According to this study, the use of a protocol can increase the likelihood that patients who need enteral nutrition (which is especially beneficial in critically ill patients) actually receive it in a timely manner.


Barr J, et al. Chest 2004;125(4):1446-57.