Building a nursing productivity measure based on the synergy model: first steps.

BACKGROUND: The Synergy Model describes nurses' work on the basis of the individual needs of patients and their families. OBJECTIVE: To generate data necessary to develop a nursing productivity system by using the Synergy Model as a conceptual framework. METHODS: Nurses from 3 different intensive care units participated. In phase 1, charge nurses in focus groups described patient and family indicators considered when making nurse-patient assignments. In phase 2, charge nurse data were used to construct a survey for experienced staff nurses, asking them to link the indicators to 3 levels of nursing workload. RESULTS: Thirty charge nurses considered all 8 patient dimensions of the Synergy Model when making nurse-patient assignments. Thirty-two experienced staff nurses completed 79 surveys ranking patients' stability as the most important dimension in patient care followed by complexity and predictability. Respondents linked a common set of unique indicators to each of the patient dimensions of the Synergy Model: fluctuation in vital signs was linked to stability; number and severity of diagnoses, to complexity; trajectory of illness, to predictability; lack of reserve, to resiliency; invasiveness of procedures, to vulnerability; family educational level and participation style, to family participation in decision making/care; and home environment, to resources. Sets of indicators were common across units and clustered around level of workload. CONCLUSION: The Synergy Model shows promise as a conceptual framework for a nursing productivity system. Using a model that centers nursing work on patients' needs may better capture what nurses do and enhance our capacity to quantify nursing resource allocation.

The incidence of dysphagia in pediatric patients after open heart procedures with transesophageal echocardiography.

BACKGROUND: Pediatric patients who undergo open heart operations may be at risk for the development of dysphagia because of interventions such as intubation and transesophageal echocardiography. Although the occurrence of dysphagia after cardiac surgical procedures in adults is reported to be 3% to 4%, the incidence in children and adolescents has not been documented. This study was undertaken to determine the incidence of and risk factors contributing to dysphagia in pediatric patients after open heart procedures. METHODS: Fifty patients were evaluated after open heart operations with transesophageal echocardiography between March 1, 1999, and September 30, 1999. The diagnosis of dysphagia was made by a speech pathologist using a clinical swallowing evaluation. Potential predictors examined included demographic variables, anatomical diagnosis, surgical procedure, size of the transesophageal echocardiographic probe in relation to body size, length of probe insertion time, preoperative patient acuity status, duration of intubation, and time until discharge. RESULTS: Dysphagia was found in 9 (18%) of the 50 patients. Risk factors identified were age of less than 3 years (odds ratio, 20.4; 95% confidence interval, 2.7 to 157; p = 0.002), intubation prior to operation (odds ratio, 17.7; 95% confidence interval, 9.4 to 210; p = 0.004), intubation for more than 7 days (odds ratio, 74.7; 95% confidence interval, 13.8 to 405; p = 0.001), and operation for left-sided obstructive lesions (odds ratio, 1.9; 95% confidence interval, 2.2 to 8.3; p = 0.038). The size of the transesophageal echocardiographic probe in relation to the weight of the patient was found to be predictive (p = 0.0001) of dysphagia. Vocal cord paralysis was noted in 4 (8%) of the 50 patients postoperatively. Adverse events related to aspiration occurred in 2 patients (4%). At discharge, nasogastric tube feedings were required in 6 patients (12%), and thickened feedings were recommended for 3 (6%) of the 50 patients. Resolution of dysphagia ranged from 13 to 150 days. CONCLUSIONS: Eighteen percent of patients had dysphagia after an open heart operation with transesophageal echocardiography. Age of less than 3 years, preoperative patient acuity status, longer intubation times, and operation for left-sided obstructions are risk factors for dysphagia in this cohort of pediatric patients. The size of the transesophageal echocardiography probe in relation to the patient's weight was predictive of dysphagia. Physicians should consider using the new mini-multiplane transesophageal echocardiographic probes in patients weighing less than 5.5 kg. Vigilance in monitoring for the signs of preoperative and postoperative dysphagia with prompt referral to a speech therapist can substantially reduce patient morbidity, length of hospital stay, and requirement of prolonged nasogastric tube use.