World views on shortage in nursing resource: Challenges and opportunities.

BACKGROUND: Shortage in nursing resource results from the combination of a lack of nurses, an increased patient volume and workload, and other factors. This seems to be a worldwide phenomenon, leading to multiple health care related challenges and a decreased quality of care, but is different in extent in high- vs. low-income countries. An international perspective can alleviate challenges to keep our patients safe through increasing our health workers' safety. PURPOSE & METHOD: To exchange experiences with the shortage in nursing resource globally, an international online conference event was hosted. Speakers from Germany, the Philippines, Poland, Tanzania, the United Kingdom and the United States presented their national challenges and strategies to deal with this phenomenon. RESULTS: Conference presentations included information about the health care systems, comparable numbers of hospital beds, nurses, and nursing education. Speakers reported challenges such as an imbalance between a high nurse vacancy rate and demands, but also war and refugees, high human immunodeficiency virus (HIV) and other infection rates, or nurses' migration to other countries; the solutions reported included buy-in from other countries, nurses-attracting projects such as Magnet hospitals, improved job opportunities like higher wages, career prospects, or improved education, and others. CONCLUSIONS: Shortage in nursing resource seems to be a global phenomenon. Nursing managers and researchers should exchange and communicate challenges and solutions continuously and cooperate globally.

Administration of Levetiracetam in Traumatic Brain Injury: Is it Warranted?

Background Antiepileptic agents are recommended to prevent early post-traumatic seizures (PTS) within seven days of injury in patients with severe traumatic brain injury (TBI). These agents are not routinely recommended for patients with mild-to-moderate TBI, defined as Glasgow Coma Scale (GCS) score > 8. At St. Joseph Mercy Oakland, levetiracetam (LEV) is commonly prescribed to prevent PTS. The objective of this study was to evaluate the appropriateness of LEV use in patients with mild, moderate, and severe TBI. Methods This retrospective cohort study evaluated the use of LEV in adult patients admitted with TBI over a five-year period. Patients who were younger than 18 years, had a history of seizures, were transferred to a tertiary center, or succumbed to their injuries were excluded. The primary outcome was appropriateness of LEV use. Secondary outcomes included duration of LEV treatment and rate of seizures. Results Of the 448 patients evaluated, 36 patients were excluded. Of the 412 included patients, 403 (97.8%) had a non-severe TBI, defined as GCS score > 8. In patients with non-severe TBI, 153 (38%) received LEV and 94 (23.3%) received LEV for more than seven days. Additionally, 105 (26.1%) patients with non-severe TBI were discharged with a prescription for LEV despite not having a seizure during hospitalization. All six patients with non-severe TBI who experienced a seizure were receiving LEV. Conclusions Inappropriate use of LEV is common in patients admitted with non-severe TBI, with many patients continuing LEV post-discharge. With careful patient selection, patients with mild and moderate TBI likely do not need seizure prophylaxis with LEV. Education on appropriate indication and duration of LEV in patients with TBI is warranted.

Withdrawal Phenomena: A Concept Analysis for the Development of a Nursing Diagnosis.

This study explored the concept of withdrawal phenomena from the perspective of nurses, with the aim of developing a nursing diagnosis. Concept analysis was used as the framework of the study, a systematized review was conducted to identify relevant studies, and interpretation was based on qualitative content analysis. Specifying aspects, defining characteristics, related factors, and risk factors were extracted and classified into categories. Thirteen studies were identified as a basis for the construction of two nursing diagnoses: "withdrawal phenomena" and "risk of withdrawal complications." The proposed nursing diagnoses require further discussion. The NANDA International Diagnosis Development Committee was asked to examine the proposed diagnoses. However, it was too early to determine implications for nursing practice based on the results of this study.

Experiences and coping strategies of oncology patients undergoing oral chemotherapy: First steps of a grounded theory study.

PURPOSE: Chemotherapies are increasingly available for oral application. Previous studies have focussed on differences between orally and intravenously administered chemotherapies, mostly following quantitative designs surveying patients' preferences and adherence. The lived experience of patients undergoing oral chemotherapy has been rarely explored. Therefore, this study investigates how patients experience oral chemotherapy. METHOD: We conducted open interviews with six patients and two spouses. Recruitment took place in the outpatient clinic of an urban Swiss hospital. Data collection and analysis followed the principles of Straussian grounded theory. RESULTS: The participants reported physical and emotional reluctance towards oral chemotherapy as well as toxic side effects. Feeling responsible emerged as a core phenomenon. All participants intended to adhere to the therapy although this was challenging because of the complex medication regimen. Belief in the effectiveness of the therapy was a strengthening factor. CONCLUSIONS: All participants reported to be highly adherent to oral chemotherapy. Although they experienced some toxic side effects, they did not react. Monitoring toxicities and support in everyday life should be a core feature of care.

Abdominal pain and hematuria: duodenal perforation from ingested foreign body causing ureteral obstruction and hydronephrosis.

Foreign body (FB) ingestion is a relatively common reason for visits to the emergency room. If the FB is symptomatic or damaging to the patient, either endoscopic or surgical intervention should ensue. We present a case of abdominal pain and hematuria beginning ∼24 h after an incidental FB ingestion. Initial CT imaging defined a linear opacity perforating through the posterior duodenal wall abutting the ureter causing inflammation and hydronephrosis. After two unsuccessful endoscopic attempts at retrieval, we were able to identify the object with the aid of intraoperative fluoroscopy and surgically remove the FB. The patient recovered uneventfully and was discharged home. Posterior duodenal perforation by an FB may not manifest with obvious localized or systemic symptoms unless the perforation involves surrounding structures such as the aorta, vena cava or ureter. In such cases, surgical intervention is required for FB removal.

Sexual Counseling in Patients With Heart Failure: A Silent Phenomenon: Results From a Convergent Parallel Mixed Method Study.

BACKGROUND: Patients with heart failure (HF) often worry about resuming sexual activity and may need information. Nurses have a role in helping patients to live with the consequences of HF and can be expected to discuss patients' sexual concerns. OBJECTIVE: The aims of this study were to identify whether nurses discuss consequences of HF on sexuality with patients and to explore their perceived role and barriers regarding this topic. METHODS: A cross-sectional research design with a convergent parallel mixed method approach was used combining qualitative and quantitative data collected with a self-reported questionnaire. RESULTS: Nurses in this study rarely addressed sexual issues with their patients. The nurses did not feel that discussing sexual concerns with their patients was their responsibility, and only 8% of the nurses expressed confidence to do so. The main phenomenon in discussing sexual concerns seems to be "one of silence": Neither patients nor nurses talk about sexual concerns. Factors influencing this include structural barriers, lack of knowledge and communication skills, as well as relevance of the topic and relationship to patients. CONCLUSION: Cardiac nurses in Germany rarely practice sexual counseling. It is a phenomenon that is silent. Education and skill-based training might hold potential to "break the silence."

Point of care ultrasound (POCUS) telemedicine project in rural Nicaragua and its impact on patient management.

BACKGROUND: Point of care ultrasound (POCUS) is a useful diagnostic tool in medicine. POCUS provides an easy and reproducible method of diagnosis where conventional radiologic studies are unavailable. Telemedicine is also a great means of communication between educators and students throughout the world. HYPOTHESIS: Implementing POCUS with didactics and hands-on training, using portable ultrasound devices followed by telecommunication training, will impact the differential diagnosis and patient management in a rural community outside the United States. MATERIALS AND METHODS: This is an observational prospective study implementing POCUS in Las Salinas, a small village in rural western Nicaragua. Ultrasound was used to confirm a diagnosis based on clinical exam, or uncover a new, previously unknown diagnosis. The primary endpoint was a change in patient management. International sonographic instructors conducted didactic and practical training of local practitioners in POCUS, subsequently followed by remote guidance and telecommunication for 3 months. RESULTS: A total of 132 patients underwent ultrasound examination. The most common presentation was for a prenatal exam (23.5 %), followed by abdominal pain (17 %). Of the 132 patients, 69 (52 %) were found to have a new diagnosis. Excluding pregnancy, 67 patients of 101 (66 %) were found to have a new diagnosis. A change in management occurred in a total of 64 (48 %) patients, and 62 (61 %) after excluding pregnancy. CONCLUSION: Implementing POCUS in rural Nicaragua led to a change in management in about half of the patients examined. With the appropriate training of clinicians, POCUS combined with telemedicine can positively impact patient care.

Predictors of Clavien 4 Complications and Mortality After Necrosectomy: Analysis of the NSQIP Database.

BACKGROUND: Acute severe pancreatitis is one of the most common gastrointestinal reasons for admission to hospitals in the USA. Up to 20 % of these patients will progress to necrotizing pancreatitis requiring intervention. The aim of this study is to identify specific preoperative factors for the development of Clavien 4 complications and mortality in patients undergoing pancreatic necrosectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant use files were reviewed from 2007 to 2012 to identify patients who underwent a pancreatic necrosectomy. Postoperative complications were stratified into Clavien 4 (ICU level complications) and Clavien 5 (mortality). Univariate and multivariate analyses were performed. RESULTS: A total of 1156 patients underwent a pancreatic necrosectomy from 2007 to 2012. Overall, 42 % of patients experienced a Clavien 4 complication. Mortality rate was 9.5 %. Nonindependent functional status and ASA class were highly significant (p < 0.001) in univariate analysis. Frailty and emergency surgery status (p < 0.001), as well as increased blood urea nitrogen (BUN) and alkaline phosphatase and decreased albumin (p < 0.05) demonstrated independent significance of Clavien 4 complications and mortality in multivariate analysis. CONCLUSION: This study identified specific preoperative variables that place patients at increased risk of Clavien 4 complications and mortality after necrosectomy. Identification of high-risk patients can aid in selection of appropriate treatment strategies and allow for informed preoperative discussion regarding surgical risk.

Assessing Risk of Critical Care Complications and Mortality in the Elective Bariatric Surgery Population Using a Modified Frailty Index.

BACKGROUND: The rate of surgical complications from bariatric procedures remains low despite an increase in volume. When serious complications occur, they are associated with an increased risk of mortality. The aim of this study is to determine if frail bariatric patients have an increased rate of Clavien level 4 and 5 complications. This study was conducted in participating hospitals in the National Surgical Quality Improvement Program (NSQIP). METHODS: The NSQIP participant use files were used to identify 104,952 patients undergoing elective bariatric procedures from 2005 to 2012. A previously described modified frailty index (mFI) was calculated based on available NSQIP variables, with a higher index suggesting more frail patients. Postoperative adverse events were stratified to Clavien levels 4 and 5 utilizing a pre-existing mapping scheme. RESULTS: Overall, 1 % of patients undergoing elective bariatric surgery experienced Clavien level 4 complications, and 0.2 % experienced a Clavien level 5 complication (mortality). Univariate analysis demonstrated that frailty was significant for both Clavien level 4 and 5 complications (p < 0.001). The mean mFI for those with Clavien level 4 complications, 0.15, was significantly higher than those without Clavien 4 complications, 0.09 (p < 0.001). Those experiencing mortality had a mean mFI of 0.17 compared to a mean mFI of 0.09 in those without mortality (p < 0.001). Frailty retained the highest odds ratio for both Clavien 4 and 5 complications in multivariate analysis compared to American Society of Anesthesiologist (ASA) class, age, sex, body mass index (BMI), and procedure type. CONCLUSIONS: Frailty may be used during patient selection to stratify bariatric surgery patients at high risk for critical care level complications.

Solid phase extractive preconcentration coupled to gas chromatography-atomic emission detection for the determination of chlorophenols in water samples.

Solid-phase extraction (SPE) followed by derivatization and gas chromatography-atomic emission detection (GC-AED) was evaluated for the determination of five chlorophenols (CPs) in water samples. The derivatization was based on the esterification of phenolic compounds with ferrocenecarboxylic acid. The determination of the derivatized phenols was performed by GC-AED in the iron selective detection mode at 302 nm. The described method was tested on spiked water samples.The overall method gave detection limits of 1.6-3.7 ng L(-1) and recoveries of 90.9-104.5% for the examined mono- to trichlorophenols in 10 mL water samples. The CPs extracted from a 10 mL water sample with SPE were concentrated into 100 µL of organic solvent, a preconcentration factor of 100. The method was applied to lake and tap water samples, and CP contents between 6 and 51 ng L(-1) in lake water and between below the detection limit and 8 ng L(-1) in tap water were found for different CPs. The method is quick, simple and gives excellent recoveries, limits of detection and standard deviations.

Attitudes of relatives of nursing home residents toward physical restraints.

PURPOSE: Attitudes of nursing home staff, residents, and their relatives determine the decision-making process about the use of physical restraints. Knowledge of staffs' attitudes toward physical restraints is sparse; even less is known about relatives' attitudes. Therefore, we surveyed relatives' attitudes and opinions toward physical restraints and compared the results to a survey of nursing home staff. DESIGN: Cross-sectional survey comparing 177 nursing home residents' relatives from 13 German facilities in 2008 to 258 nursing home nurses from 25 German facilities in 2007. METHODS: The German version of the Maastricht Attitude Questionnaire was administered. Part I contains 22 items with three subscales (reasons, consequences, and appropriateness of restraints); Part II contains 16 items evaluating restrictiveness and discomfort of restraint measures, respectively. Descriptive and explorative inferential statistics were used for data analyses. FINDINGS: Response rate in both samples was above 90%. Mean age was 62 years (SD 12.60; range 24-93) in relatives and 44 years (SD 11.40; range 19-65) in nurses; 72% and 82% were female, respectively. Relatives assess physical restraints a little more positively compared to nurses, with an average of 3.40 (SD 0.60) versus 3.07 (SD 0.48) on a 5-point scale (5=strongly positive attitude). Relatives assess physical restraints as slightly less restrictive, with 2.11 (SD 0.33), and as less discomforting, with 2.10 (SD 0.38) points, compared to nursing staff, who assess the restraints' restrictiveness with 2.19 (SD 0.29) points and its discomfort with 2.17 (SD 0.32) on a 3-point scale (3=very restrictive/discomforting). Both groups consider wrist and ankle belts as most restrictive and uncomfortable, while sensor mats, infrared systems, and unilateral bedrails were rated as the lowest for restrictiveness and discomfort. CONCLUSIONS: Attitudes of nursing home residents' relatives toward physical restraints are rather positive and generally comparable with nursing home staffs' attitudes. CLINICAL RELEVANCE: Interventions aimed to reduce physical restraints need to include education of both staff and relatives of nursing home residents.

The renal diet in 2010: is it time for a shake up?

Food manufacturers add phosphate salts to their products to act as a preservative to extend shelf life. However, this added phosphorus poses a problem for dialysis patients and their caregivers because it is difficult to quantify the amount of phosphorus in a patient's diet. This article discusses the difference between organic and inorganic phosphorus, how the added phosphorus affects previously safe food choices, and the need to update renal diet information so hemodialysis patients can more effectively track their intake.

[Living with limitations: people afflicted with heart failure - A qualitative study]. / Leben mit chronischer Herzinsuffizienz - Eine qualitative Studie in Anlehnung an die Grounded Theory.

About two million people in Germany live with heart failure. However, health care provision is still inadequate. In order to develop patient-centred care it is necessary to focus on the everyday life and experiences of people with heart failure. Based on these insights the need for information and counselling can be identified and nursing interventions can be designed according to these needs. Within a literature analysis five international but no German studies. The focus lay on everyday experiences of people suffering from heart failure. The following research question was developed: How do people with heart failure experience their lives? Using the Grounded Theory approach, nine interviews and a self-report were analysed according to Corbin and Strauss' coding paradigm. The central phenomenon found is the experience of limitations. To deal with these limitations in everyday life, patients develop two different strategies: ignorance or acceptance. Either they ignore the limitations in order to maintain their former life or they create a new normality by adopting the illness and its symptoms. The different strategies have special impacts on the person's roles, their emotions their everyday lives, and their families. The results of this study underline existing theories of chronic illness as well as results of current studies. It provides an insight into the perspective of people suffering from heart failure in Germany. But many questions are still unanswered so that further research needs to be done.

[New models to improve supply in patients with chronic heart failure]. / Neue Versorgungsstrukturen für Patienten mit chronischer Herzinsuffizienz.

Frequency of chronic heart failure still increases. More and more resources have been required for the diagnosis and therapy of this disease. This burden for health-care systems will grow in the near future. In particular, clinical treatment has a major impact. New approaches are essential to ensure an efficient supply of patients with chronic heart failure in the next years. Models to improve the supply give the opportunity to optimize the medical workflow and involve the patient into the concept of care. Therefore, a variety of models have been developed and up to now tested concerning benefit and applicability in western industrial countries. The present article focuses on the fundamental models to improve the supply of patients with chronic heart failure.

Simple and sensitive determination of o-phenylphenol in citrus fruits using gas chromatography with atomic emission or mass spectrometric detection.

In this work, a simple and sensitive method for the analysis of the pesticide o-phenylphenol (OPP) on citrus fruits was developed. OPP is extracted with dichloromethane by ultrasonication and derivatized with ferrocenecarboxylic acid chloride. Using ferrocene as a label, residues of OPP are determined by gas chromatography with atomic emission detection in the iron selective mode or with mass spectrometric detection. Sample cleanup is simple and rapid and merely involves a removal of excess reagent on an alumina minicolumn. The method detection limit is 2 ng of OPP/g of fruit, and recoveries from lemon samples fortified at levels of 35 and 140 ng/g are 101 and 106%, respectively. The citrus fruits analyzed (oranges, grapefruits, lemons) contained between 60 ng/g and 0.37 microg/g OPP (RSD = 8-13%), and the results were in good agreement with results obtained when OPP was analyzed using an established HPLC-FLD method. Several alcohols could also be identified in the fruit peel.