Reduction of Postoperative Infections Through Routine Preoperative Universal Decolonization of Advanced Heart Failure Patients With Chlorhexidine and Mupirocin Before Left Ventricular Assist Device Implantation: A Single-Center Observational Study.

BACKGROUND: Left ventricular assist devices (LVADs) are increasingly being used in patients with advanced heart failure as bridge to transplant, bridge to decision, or destination therapy. Infections are a major complication associated with LVADs. Staphylococcus aureus is one of the common causative organisms associated with LVAD infections. Methicillin resistant staphylococcus aureus (MRSA)-colonized patients are at an increased risk for developing MRSA-associated infections. Various studies have demonstrated decolonization of skin with topical chlorhexidine and nares with 2% intranasal mupirocin ointment is effective in reducing MRSA-associated infections. OBJECTIVE: The objective of this observational study was to examine the impact of a universal decolonization protocol using topical chlorhexidine and intranasal mupirocin ointment for 5 days before LVAD implantation on postoperative infections (30, 60, and 90 days) and 30-day infection-related rehospitalization. METHODS: A preoperative universal decolonization with 4% chlorhexidine daily whole-body bath and 2% intranasal mupirocin ointment twice a day for 5 days was implemented for patients undergoing elective LVAD implantation. Using an observational study design, we included a convenience sample of 84 subjects who were established patients in an accredited advanced heart failure program. Thirty-seven patients served in the standard protocol group, and 47 in the universal decolonization protocol group participated in the observational study. RESULTS: In the standard protocol group, there were 4 MRSA infections with none in the universal decolonization group (χ = 5.34, P = .03). In total, there were 8 surgical site infections in the standard protocol group and 1 in the universal decolonization group (χ = 5.95, P = .01). CONCLUSION: A 5-day universal decolonization protocol before LVAD implantation was effective in reducing total infections as well as MRSA-specific infections.

Use and Effectiveness of the Teach-Back Method in Patient Education and Health Outcomes.

A review of the literature on the teach-back method of education suggests that the technique may be beneficial in reinforcing patient education.

Interventions for the Management of Respiratory Distress in Late Preterm and Term Infants Experiencing Delayed Respiratory Transition: A Systematic Review.

OBJECTIVES: To examine the best available evidence for interventions used to manage mild to moderate respiratory distress in late preterm and term infants experiencing delayed respiratory transition. DATA SOURCES: EMBASE, MEDLINE, Cochrane Review, Joanna Briggs, PubMed, CINAHL, and Google Scholar online databases were searched for articles related to delayed respiratory transition. Reference lists were reviewed to identify additional articles for inclusion. STUDY SELECTIONS: Randomized, blinded, placebo-controlled, randomized prospective, prospective observational, and retrospective cohort studies published in English-language, peer-reviewed journals between 2007 and August 2017 were reviewed for inclusion. Studies were included if they examined respiratory focused interventions that could potentially prevent admission to the neonatal intensive care unit (NICU) of the term or late preterm infant transitioning to extrauterine life. DATA EXTRACTION: The CASP tools were utilized for appraisal of individual studies. Data were extracted from the 5 studies included in this review. DATA SYNTHESIS: In 4 of the 5 studies, prevention of NICU admission was the primary aim. The observational study observed videos of newborn resuscitations and described the effect of early intervention with continuous positive-airway pressure (CPAP) ventilation on prevention of NICU admission for respiratory distress. One randomized controlled trial used adrenaline injections to prevent development of respiratory distress. The 3 remaining randomized controlled trials used prophylactic CPAP or sustained inflation as a method for preventing development of delayed respiratory transition. Three of the 5 studies focused exclusively on cesarean born infants. Among the interventions studied, early or prophylactic CPAP shows the most promise for prevention of NICU admission in late preterm and term infants with mild to moderate respiratory distress. CONCLUSION: The lack of safety and efficacy data for either adrenaline injections or prophylactic CPAP precludes either method for current use in the prevention of respiratory distress for the late preterm or term infant transitioning to extrauterine life. Two randomized trials, both using prophylactic CPAP, had a significant decrease in NICU admissions. Both studies were conducted at a single center and exclusive to infants born by cesarean delivery. A single study using sustained lung inflation showed no significant difference in the need for respiratory support or NICU admission. A single study using adrenaline also showed no benefit to the prevention of respiratory distress related to transition. Further multicenter randomized controlled trials are needed before broad adoption of early or prophylactic CPAP can be recommended.

The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality: A Systematic Review.

BACKGROUND: The Affordable Care Act of 2010 set forth payment models that provided $10 billion to incent the health care system in developing innovative programs that target reform, including transitional care to reduce preventable readmissions. While transitional care programs exist, US hospitals remain challenged, with 1 in 5 readmissions within 30 days. OBJECTIVE: This systematic review examined the effectiveness of select evidence-based transitions-of-care interventions on reducing 30-day readmission rates, reducing emergency room visits, and reducing mortality rates. METHODS: The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines formed the framework for this systematic review. Key study characteristics informed the eligibility criteria and search strategy. Two reviewers independently appraised selected studies using the Critical Appraisal Skills Programme tools. Included studies were summarized and synthesized in order to draw conclusions across studies. RESULTS: Interventions are aimed at reducing the readmission rate of the adult general medical population. The population of focus in this review includes patients at risk of avoidable readmissions, which includes patients requiring higher levels of care secondary to complications that can contribute to higher mortality after discharge from an acute care setting. DISCUSSION: The findings of this review support the use of transitions-of-care interventions such as tailored discharge planning and postdischarge phone calls.

Comparison of Rectal and Esophageal Sensitivity in Women With Functional Heartburn.

This study tested the primary hypothesis that there is a correlation of maximum pain threshold (MPT) in the esophagus and rectum in persons with functional heartburn. Secondary aims evaluated correlations with initial perception threshold (IPT) and pain threshold (PT). This study explored objective sensory endpoints of IPT, PT, and MPT in the esophagus and rectum of 14 females with functional heartburn to determine whether visceral hypersensitivity is generalized or organ-specific. Data on volume and pressure measurements at IPT, PT, and MPT with esophageal and rectal barostat distention were collected. The relationship of sensation and pain to volume, pressure, and compliance was analyzed. Esophageal and rectal IPT balloon volume scores were highly and significantly correlated (r = .61, p = .02). Esophageal and rectal PT balloon volume scores were highly and significantly correlated (r = .6, p = .02). Esophageal and rectal MPT balloon volume scores were not correlated (r = .35, p = .26). The correlation of visceral sensitivity in the esophagus and rectum in persons with functional heartburn supports the hypothesis that visceral sensory changes in functional gastrointestinal disorders are not organ specific.

Effectiveness of Decolonization With Chlorhexidine and Mupirocin in Reducing Surgical Site Infections: A Systematic Review.

BACKGROUND: Surgical site infections (SSI) are a serious complication of surgery. Staphylococcus aureus (S aureus) is 1 of the most common causative organisms responsible for SSI. Patients who are carriers of methicillin-resistant S aureus and methicillin-sensitive S aureus are at increased risk of developing S aureus-associated SSIs. Decolonization of skin with chlorhexidine and nares with mupirocin may reduce the risk of SSI. OBJECTIVE: The primary object of this systematic review is to examine the effectiveness of preoperative universal decolonization of skin with chlorhexidine and nares with intranasal mupirocin in preventing SSIs. METHODS: The following databases were searched: Ovid Medline (from 1946 to September week 3, 2015), Embase (1947 to 2015, week 38), EBSCO CINHAL (1980-2015), Cochrane Collaboration for Systematic Reviews, EBM Reviews, and Google Scholar. STUDY SELECTION: All experimental and nonexperimental studies that evaluated the effect of chlorhexidine in combination with intranasal mupirocin for decolonization were included. Inclusion was limited to published studies written in English. A total of 19 studies were included in this review. One study was deleted from final analysis as other agents were used for skin decolonization. DATA EXTRACTION: Data were extracted independently by 2 members of the study team. Discrepancies were resolved through discussion. RESULTS: Decolonization with topical chlorhexidine and intranasal mupirocin resulted in reduction of S aureus SSI and methicillin-resistant S aureus nosocomial infection and eradication of S aureus nasal carriage. Incidence of SSIs was significantly reduced in 10 studies, which was the primary outcome. Four of the 10 studies used preoperative universal decolonization and significant reduction in SSI was observed in cardiac and orthopedic patients. CONCLUSION: The results of this review indicate the combination of topical chlorhexidine and intranasal mupirocin is effective in reducing S aureus-associated SSIs.

Application of Transformational Leadership Principles in the Development and Integration of Palliative Care Within an Advanced Heart Failure Program.

Heart failure (HF) is a major health problem in United States, and it has reached epidemic proportions. Heart failure is associated with significant morbidity, mortality, and cost. Although the prognosis of HF is worse than many forms of cancer, many patients, families, and clinicians are unaware of the dire prognosis. As the disease progress to advanced HF, patients are faced with many challenges, such as poor quality of life due to worsening symptoms and frequent hospitalizations. Heart failure management adds significant financial burden to the health care system. Palliative care can be integrated into HF care to improve quality of life and symptom management and to address physical, spiritual, and psychosocial needs of patients and families. Palliative care can be used concurrently with or independent of curative or life-prolonging HF therapies. Transformational leadership principles were used to guide the development of a plan to enhance integration of palliative care within traditional advanced HF care.

Implementation of a rapid chest pain protocol in the emergency department: A quality improvement project.

PURPOSE: The purpose of this quality improvement (QI) project is to compare the effectiveness of a rapid 90-min chest pain screening and evaluation protocol to a 120-min screening and evaluation protocol in determining patient readiness for hospital admission or discharge home. DATA SOURCES: The existing chest pain protocol utilized in the emergency department (ED) was revised based on a review of current research changing initial screening and reevaluation times from 120 to 90 min. A prospective comparative study of patients presenting to the ED with chest pain was performed comparing the existing chest pain protocol of 120 min (standard care) with a rapid screening evaluation protocol of 90 min. A total of 128 patients presenting to an ED in Texas with chest pain comprised the sample for this study. CONCLUSIONS: There was a significant difference in the number of minutes between the groups for readiness for disposition. The average time from chest pain evaluation to readiness for disposition home, observation, or admission decreased from an average of 191 min in the standard care group to an average of 118 min in the rapid screening group. IMPLICATIONS FOR PRACTICE: Use of the rapid screening and evaluation protocol decreased the time to disposition by an average of 73 min, which enhanced ED flow without influencing disposition and patient safety.

Use of a 90-minute protocol to evaluate patients presenting to the emergency department with chest pain: a case study.

Frustration with emergency department wait times may contribute to patient delays in seeking care for subsequent episodes of chest pain and lower patient satisfaction ratings. In response to patient feedback and the dissemination of new knowledge, the existing emergency chest pain protocol was updated to include point-of-care laboratory testing and evaluation at baseline and 90 minutes. A case study was utilized to illustrate implementation of this protocol in the management of a patient presenting to the emergency department with chest pain.

Health promotion for the oldest of old people.

AIM: The aim of this study was to explore the factors that contribute to health promotion in the oldest old and the barriers that prevent it. METHOD: A non-random sample (n = 52) of people aged 80 and older participated in a descriptive correlational study. Respondents completed a series of two Likert-type questionnaires. The Health Promoting Lifestyle Profile II (Walker et al 1995) and Barriers to Health Promoting Activities for Disabled Persons Scale (Becker et al 1991) were used to measure health behaviours. RESULTS: Differences were noted between the age groups (80-90 and 91-101) for health responsibility, physical activity and nutrition. Impairment was the major barrier to health promotion. CONCLUSION: To foster optimal living, the health, illness, function and motivation as well as age of older adults must be considered. They should be encouraged to pursue physical, social and intellectual activity, which can enable them to have active and fulfilling lives.

Prevention of ventilator-associated pneumonia through aspiration of subglottic secretions: a systematic review and meta-analysis.

Ventilator-associated pneumonia (VAP) is a subset of hospital-acquired pneumonias and is a serious, sometimes fatal, complication in patients who need mechanical ventilation. In addition, pay-for-performance initiative has placed increased emphasis on preventing nosocomial infections including VAP. Facilities may not be reimbursed for costs associated with prevalence infections. This article presents a review and meta-analysis of the prevention of VAP through the aspiration of subglottic secretion.

Aging in America: quality of life among older Vietnamese women immigrants.

The purpose of this ethnographic research was to describe factors related to and elicit the meaning of "quality of life" in a group of older Vietnamese women immigrants. Thirty-three women who emigrated from Vietnam to the United States after 1978 participated in audiotaped interviews. Ethnographic content analysis was used to identify themes and categories. Major theme ofresiliency and security were identified. The elements of health, functional status and social support were consistent with quality of life concepts described by Flanagan; and, George and Bearon while leisure and recreation was not present.

Situational challenges that impact health adherence in vulnerable populations.

This pilot study identified situations related to lifestyle conditions and/or patient rationales that motivated or discouraged military veterans from adhering to prescribed therapies. Adherence to recommendations associated with medication, diet, and exercise enhanced self-management of their chronic disease. Nurses need to understand adherent behavior and roadblocks to adherence in order to produce successful health outcomes. Individual, face-to-face interviews with 30 subjects from the Department of Veterans Affairs Medical Center (VAMC) in the South Central United States VAMC primary care and specialty clinics were analyzed using a descriptive, qualitative approach. Analysis for treatment adherence revealed six themes: forgetfulness/unintentional omission, intentional omission-personal judgment to discontinue or alter, routine/reminders, diet deviation, exercise routine and exercise deviation. Adherence in health care is extremely important but not always predictable because of a client's individual situation and lifestyle. This study offers interesting insights to adherent and non-adherent behavior.

Health information literacy: hardwiring behavior through multilevels of instruction and application.

To produce a healthcare provider who is competent in accessing health information, nursing faculty members, in tandem with medical librarians, play a crucial role in establishing the knowledge base for student competency in health information literacy. The time to prepare nursing students to meet the information challenges and opportunities of today's healthcare environment is not after graduation, but rather while they are in school. By incorporating health information literacy skill building throughout the curriculum, nursing faculty members can prepare their students to enter the workforce equipped with the skills they need to find, retrieve, appraise, and apply information to their clinical practice.

Barriers and facilitators to the use of evidence-based best practices.

The continued use of healthcare interventions without an evidence base increases healthcare costs without positively impacting patient care outcomes. Reports disseminated by bodies such as the Institute of Medicine and initiatives such as the Institute for Health Care Improvement's 5 Million Lives Campaign have increased emphasis on improving outcomes. Results of a descriptive correlational study indicated that 64% of the nurses surveyed read 7 or more specialty journals, 53% read 1 or more general nursing journal, 20% did not regularly read any professional journal, and none of the nurses surveyed read a journal that was primarily dedicated to the publication of original research. Almost half of the nurses indicated that the hospital library was the nearest location to conduct searches, and 34% indicated that they did not know what literature-searching capabilities were available to them. Although knowledge in itself is not sufficient for behavior change, it is an essential prerequisite. Regular reading of journals either through personal subscriptions or access through facility libraries can encourage the adoption of new evidence through lifelong learning. Modeling and skill building in use of readily available Internet resources can serve as a mechanism to increase awareness of and skill in accessing current information. Evidence-based changes can then be empirically examined, implemented, and evaluated in examining nursing's contribution to the daily operation of the healthcare organization.