The experiences of critical care nurses caring for patients with COVID-19 during the 2020 pandemic: A qualitative study.

AIM: Due to a lack of literature about US critical care nurses caring for patients with coronavirus disease 2019 (COVID-19), the aim of this study was to examine their experiences caring for these patients. BACKGROUND: COVID-19 placed nurses at the forefront of battling this pandemic in the intensive care unit (ICU). Emerging international evidence suggests nurses experience psychological and physical symptoms as a result of caring for these patients. METHODS: A qualitative descriptive design was used. Using purposive sampling, 11 nurses from one ICU participated in semi-structured interviews. Interviews were recorded and coded; data were analyzed using content analysis. An audit trail was maintained and member checking was employed. RESULTS: The experiences among critical care nurses caring for patients diagnosed with COVID-19 were categorized into five themes and subthemes. Emotions experienced was subcategorized into anxiety/stress, fear, helplessness, worry, and empathy. Physical symptoms was subcategorized into sleep disturbances, headaches, discomfort, exhaustion, and breathlessness. Care environment challenges was subcategorized into nurse as surrogate, inability to provide human comforting connection, patients dying, personal protective equipment (PPE), isolation, care delay, changing practice guidelines, and language barrier. Social effects was subcategorized into stigma, divergent healthcare hero perception, additional responsibilities, strained interactions with others, and isolation/loneliness. Short term coping strategies was subcategorized into co-worker support, family support, distractions, mind/body wellness, and spiritualty/faith. CONCLUSION: ICU nurses are experiencing intense psychological and physical effects as a result of caring for patients diagnosed with COVID-19 in a challenging care environment. Outside of work, nurses faced pandemic-induced societal changes and divergent public perceptions of them.

Quality of Best Possible Medication History upon Admission to Hospital: Comparison of Nurses and Pharmacy Students and Consideration of National Quality Indicators.

BACKGROUND: Medication reconciliation at transitions of care increases patient safety. Collection of an accurate best possible medication history (BPMH) on admission is a key step. National quality indicators are used as surrogate markers for BPMH quality, but no literature on their accuracy exists. Obtaining a high-quality BPMH is often labour- and resource-intensive. Pharmacy students are now being assigned to obtain BPMHs, as a cost-effective means to increase BPMH completion, despite limited information to support the quality of BPMHs obtained by students relative to other health care professionals. OBJECTIVES: To determine whether the national quality indicator of using more than one source to complete a BPMH is a true marker of quality and to assess whether BPMHs obtained by pharmacy students were of quality equal to those obtained by nurses. METHODS: This prospective trial compared BPMHs for the same group of patients collected by nurses and by trained pharmacy students in the emergency departments of 2 sites within a large health network over a 2-month period (July and August 2016). Discrepancies between the 2 versions were identified by a pharmacist, who determined which party (nurse, pharmacy student, or both) had made an error. A panel of experts reviewed the errors and ranked their severity. RESULTS: BPMHs were prepared for a total of 40 patients. Those prepared by nurses were more likely to contain an error than those prepared by pharmacy students (171 versus 43 errors, p = 0.006). There was a nonsignificant trend toward less severe errors in BPMHs completed by pharmacy students. There was no significant difference in the mean number of errors in relation to the specified quality indicator (mean of 2.7 errors for BPMHs prepared from 1 source versus 4.8 errors for BPMHs prepared from ≥ 2 sources, p = 0.08). CONCLUSIONS: The surrogate marker (number of BPMH sources) may not reflect BPMH quality. However, it appears that BPMHs prepared by pharmacy students had fewer errors and were of similar quality (in terms of clinically significant errors) relative to those prepared by nurses.

CONTEXTE: L'établissement du bilan comparatif des médicaments au moment du transfert des soins accroît la sécurité des patients. L'obtention d'un meilleur schéma thérapeutique possible (MSTP) exact à l'admission en est une étape clé. Des indicateurs nationaux de la qualité sont utilisés comme critères de substitution pour évaluer la qualité des MSTP, mais il n'y a pas de documentation se penchant sur leur exactitude. Obtenir un MSTP de grande qualité est souvent exigeant sur le plan du personnel et des ressources. Des étudiants en pharmacie se voient maintenant confier l'élaboration de MSTP, une façon peu coûteuse d'accroître les taux de réalisation de MSTP; or, il n'y a que peu d'information pour valider le degré de qualité des MSTP obtenus par des étudiants en comparaison avec ceux produits par d'autres professionnels de la santé. OBJECTIFS: Déterminer si l'indicateur national de qualité basé sur le recours à plus d'une source de renseignements pour réaliser un MSTP est un vrai marqueur de qualité et évaluer la qualité relative des MSTP de la part des étudiants en pharmacie et du personnel infirmier. MÉTHODES: Dans la présente étude prospective réalisée sur une période de deux mois (en juillet et en août 2016), les chercheurs ont comparé les MSTP recueillis auprès du même groupe de patients par du personnel infirmier et par des étudiants en pharmacie qualifiés dans les services des urgences de deux établissements faisant partie d'un important réseau de santé. Un pharmacien relevait les divergences entre les deux versions du MSTP et imputait l'erreur soit au personnel infirmier, soit à l'étudiant en pharmacie ou soit aux deux parties. Un groupe d'experts a étudié les erreurs et leur a accordé une cote selon leur degré de gravité. RÉSULTATS: Des MSTP ont été réalisés auprès de 40 patients. Ceux préparés par le personnel infirmier étaient plus susceptibles de contenir une erreur que ceux établis par les étudiants en pharmacie (171 contre 43 erreurs, p = 0,006). On a noté une tendance non significative selon laquelle les erreurs commises par les étudiants en pharmacie étaient moins graves. Aucune différence significative n'a été relevée quant au nombre moyen d'erreurs par rapport à l'indicateur de qualité (2,7 pour les MSTP provenant d'une source contre 4,8 pour les MSTP provenant de deux sources ou plus, p = 0,08). CONCLUSIONS: Le critère de substitution (nombre de sources pour le MSTP) pourrait ne pas être représentatif de la qualité du MSTP. Cependant, il semble que les MSTP préparés par les étudiants en pharmacie comportaient moins d'erreurs et étaient de qualité comparable (quant aux erreurs cliniquement significatives) à ceux établis par le personnel infirmier.

Strict versus liberal insulin therapy in the cardiac surgery patient: An evidence-based practice development, implementation and evaluation project.

BACKGROUND: Hyperglycemia post-cardiac surgery is associated with poor clinical outcomes. Recent studies suggest maintaining liberal glycemic control (<180mg/dL) using a continuous insulin infusion (CII) versus strict control achieves optimal outcomes and prevents hypoglycemia. PURPOSE: To develop, implement and evaluate a nurse managed liberal CII protocol. METHODS: Retrospective review of 144 strict CII patient records and 147 liberal CII patient records. RESULTS: Mean blood glucose was 159.8mg/dL (liberal CII) compared to 143.3mg/dL (strict CII) (p≤0.001). No surgical site infections occurred in either group. Mean ICU length of stay was 4.5days (liberal) versus 4.4days (strict) (p=0.74). Two 30-day mortalities occurred for the liberal cohort compared to no deaths in the strict group (p=0.49). Hypoglycemia incidence within 24h after surgery was 0.1% (liberal) compared to 0.3% (strict) compared to (p=0.16). CONCLUSION: Use of a nurse managed liberal CII resulted in similar outcomes with fewer incidents of hypoglycemia.

Video-assisted thoracic surgery micro pneumonectomy, a new approach.

BACKGROUND: Video-assisted thoracic surgery (VATS) pneumonectomy is normally limited due to the difficulty to remove the whole lung via the utility incision. We present our technique of VATS pneumonectomy, this we call micropneumonectomy. METHODS: A 75-year-old male current smoker with a right hilar mass, invading both upper and lower lobe bronchi to segmental level on CT scan and PET scan, pathology from CT guided biopsy showed squamous cell carcinoma. The patient had a mediastinoscopy just prior to pneumonectomy, primarily to remove station 7 lymph nodes and to mobilize the carina to facilitate the VATS pneumonectomy. RESULTS: Smooth postoperative course, and patient was fit for discharge two and half days post operatively. CONCLUSIONS: Our technique showed an effective way of doing pneumonectomy via VATS technique, which expands the use of VATS technique into pneumonectomies, with three intercostals incisions smaller than 5 mm, in addition to a single sub-xiphoid incision which can take 12 mm instruments.

Canadian†Stroke†Best†Practice†Recommendations: Hyperacute Stroke Care Guidelines, Update 2015.

The 2015 update of the Canadian Stroke Best Practice Recommendations Hyperacute Stroke Care guideline highlights key elements involved in the initial assessment, stabilization, and treatment of patients with transient ischemic attack (TIA), ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and acute venous sinus thrombosis. The most notable change in this 5th edition is the addition of new recommendations for the use of endovascular therapy for patients with acute ischemic stroke and proximal intracranial arterial occlusion. This includes an overview of the infrastructure and resources required for stroke centers that will provide endovascular therapy as well as regional structures needed to ensure that all patients with acute ischemic stroke that are eligible for endovascular therapy will be able to access this newly approved therapy; recommendations for hyperacute brain and enhanced vascular imaging using computed tomography angiography and computed tomography perfusion; patient selection criteria based on the five trials of endovascular therapy published in early 2015, and performance metric targets for important time-points involved in endovascular therapy, including computed tomography-to-groin puncture and computed tomography-to-reperfusion times. Other updates in this guideline include recommendations for improved time efficiencies for all aspects of hyperacute stroke care with a movement toward a new median target door-to-needle time of 30 min, with the 90th percentile being 60 min. A stronger emphasis is placed on increasing public awareness of stroke with the recent launch of the Heart and Stroke Foundation of Canada FAST signs of stroke campaign; reinforcing the public need to seek immediate medical attention by calling 911; further engagement of paramedics in the prehospital phase with prehospital notification to the receiving emergency department, as well as the stroke team, including neuroradiology; updates to the triage and same-day assessment of patients with transient ischemic attack; updates to blood pressure recommendations for the hyperacute phase of care for ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. The goal of these recommendations and supporting materials is to improve efficiencies and minimize the absolute time lapse between stroke symptom onset and reperfusion therapy, which in turn leads to better outcomes and potentially shorter recovery times.

The use of octreotide in the treatment of chylothorax following cardiothoracic surgery.

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Is octreotide (a long-acting somatostatin analogue) effective in patients with post-operative or traumatic chylothorax as a part of conservative management to reduce lymphorrhagia?' Altogether 180 papers were found using the reported search, of which 20 represented the best evidence to answer the clinical question. One case was reported twice and therefore was excluded, leaving us with 19 papers. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Although rare, iatrogenic and traumatic chylothorax have been well described in the literature. At present, there have been no randomized controlled clinical trials on the use of octreotide in chylothorax. Sixteen of 19 papers found octreotide to be effective in the treatment of chylothorax. Octreotide was found to have no complementary effect in three reports. Two of the papers were retrospective studies: one a randomized controlled trial in canines, and the remainder were case reports and case series. The two retrospective studies showed a success rate of 87-90% in the use of octreotide as an adjunct to conservative management for the treatment of chylothorax and hence preventing the need for further surgery. Experimental study in canines has shown significant drain reduction and earlier fistula closure, although transferability of this result to human is difficult to interpret. Twelve case reports found octreotide effective in reduction of the volume and arrest of chylothorax. Most reported benefit in 2-3 days of administration of octreotide. The general consensus is for conservative management with octreotide to be instituted for 1 week before consideration of surgery, although some authors have advocated for a large volume chylothorax, especially after oesophageal surgery with no response to conservative management with octreotide, to be operated on sooner. We concluded that octreotide is effective in the management of moderate to large volume chylothorax.

Recurrent Wilms tumour presenting as bilateral pneumothoraces.

We report the case of a 14-year-old girl who presented with bilateral pneumothoraces secondary to recurrent Wilms' tumour, 10 years following the initial treatment of her tumour. Recurrent Wilms' tumour presenting as bilateral pneumothorax so long after the original diagnosis has not previously been reported.