Intensive care unit nurses' perceptions of safety after a highly specific safety intervention.

BACKGROUND: It is unknown if successful changes in specific safety practices in the intensive care unit (ICU) generalize to broader concepts of patient safety by staff nurses. OBJECTIVE: To explore perceptions of patient safety among nursing staff in ICUs following participation in a safety project that decreased hospital acquired infections. METHOD: After implementation of practices that reduced catheter-related bloodstream infections in ICUs at four community hospitals, ICU nurses participated in focus groups to discuss patient safety. Audiotapes from the focus groups were transcribed, and two independent reviewers categorised the data which were triangulated with responses from selected questions of safety climate surveys and with the safety checklists used by management leadership on walk rounds. RESULTS: Thirty-three nurses attended eight focus groups; 92 nurses and managers completed safety climate surveys, and three separate leadership checklists were reviewed. In focus groups, nurses predominantly related patient safety to dangers in the physical environment (eg, bed rails, alarms, restraints, equipment, etc.) and to medication administration. These areas also represented 47% of checklist items from leadership walk rounds. Nurses most frequently mentioned self-initiated "double checking" as their main safety task. Focus-group participants and survey responses both noted inconsistency between management's verbal and written commitment compared with their day-to-day support of patient safety issues. CONCLUSIONS: ICU nurses who participated in a project to decrease hospital acquired infections did not generalize their experience to other aspects of patient safety or relate it to management's interest in patient safety. These findings are consistent with many adult learning theories, where self-initiated tasks, combined with immediate, but temporary problem-solving, are stronger learning forces than management-led activities with delayed feedback.

Automated computerized intensive care unit severity of illness measure in the Department of Veterans Affairs: preliminary results. SISVistA Investigators. Scrutiny of ICU Severity Veterans Health Sysyems Technology Architecture.

OBJECTIVE: To evaluate the feasibility of an automated intensive care unit (ICU) risk adjustment tool (acronym: SISVistA) developed by selecting a subset of predictor variables from the Acute Physiology and Chronic Health Evaluation (APACHE) III available in the existing computerized database of the Department of Veterans Affairs (VA) healthcare system and modifying the APACHE diagnostic and comorbidity approach. DESIGN: Retrospective cohort study. SETTING: Six ICUs in three Ohio Veterans Affairs hospitals. PATIENT SELECTION: The first ICU admission of all patients from February 1996 through July 1997. OUTCOME MEASURE: Mortality at hospital discharge. METHODS: The predictor variables, including age, comorbidity, diagnosis, admission source (direct or transfer), and laboratory results (from the +/- 24-hr period surrounding admission), were extracted from computerized VA databases, and APACHE III weights were applied using customized software. The weights of all laboratory variables were added and treated as a single variable in the model. A logistic regression model was fitted to predict the outcome and the model was validated using a boot-strapping technique (1,000 repetitions). MAIN RESULTS: The analysis included all 4,651 eligible cases (442 deaths). The cohort was predominantly male (97.5%) and elderly (63.6 +/- 12.0 yrs). In multivariate analysis, significant predictors of hospital mortality included age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.04-1.09), comorbidity (OR, 1.11; 95% CI, 1.08-1.15), total laboratory score (OR, 1.07; 95% CI, 1.06-1.08), direct ICU admission (OR, 0.39; 95% CI, 0.31-0.49), and several broad ICU diagnostic categories. The SISVistA model had excellent discrimination and calibration (C statistic = 0.86, goodness-of-fit statistics; p > .20). The area under the receiver operating characteristic curve of the validated model was 0.86. CONCLUSIONS: Using common data elements often found in hospital computer systems, SISVistA predicts hospital mortality among patients in Ohio VA ICUs. This preliminary study supports the development of an automated ICU risk prediction system on a more diverse population.

Patients with stable chronic obstructive pulmonary disease can safely undergo intravenous dipyridamole thallium-201 imaging.

BACKGROUND: Patients with chronic obstructive pulmonary disease are usually excluded from intravenous dipyridamole thallium-201 testing. We developed a nurse-administered protocol to screen and pretreat patients so they could be safely tested. METHODS AND RESULTS: We prospectively screened patients referred for intravenous dipyridamole thallium testing and retrospectively reviewed a comparison group of patients who had undergone intravenous dipyridamole testing before our bronchospasm protocol. We studied 492 consecutive patients referred for intravenous dipyridamole thallium testing, separating those with complete data (n = 451) into two groups: group A (n = 72), patients assessed to be at risk for intravenous dipyridamole-induced bronchospasm who received our bronchospasm treatment protocol; and group B (n = 379), patients assessed to be free of risk, who did not receive our bronchospasm protocol. Group C (n = 89) was a retrospective comparison group of patients who had undergone intravenous dipyridamole testing before initiation of the protocol. Patients were considered at risk for an adverse event if any of the following were present: peak flow < or =400 ml at the time of the test (spirometry by nurse) that increased to >400 ml after bronchodilator treatment, wheezing audible with stethoscope, history of chronic obstructive pulmonary disease or asthma or dyspnea on exertion at less than four blocks, or resting respiratory rate >18 breaths/min. The test was considered contraindicated if resting oxygen saturation was <85%, respiratory rate < or =36 breaths/min, or peak flow measured by peak flowmeter <400 ml after bronchodilator inhalant (albuterol or metaproterenol sulfate by spacer) at a dose of up to six puffs. One minute after injections of thallium-201, patients at risk were given 50 mg aminophylline by slow intravenous injection. We looked for major and minor adverse effects and divided them into three categories: (1) minor events (transient headache, abdominal discomfort, or nausea), wheezing (audible by stethoscope but without marked respiratory distress), (2) marked events (severe bronchospasm or severe ischemia defined as wheezing audible with or without stethoscope, respiratory rate >20 breaths/min or increased by 10 from pretest evaluation, oxygen desaturation to <90%, hypoventilation [reduced respiratory rate with decreased mental status], respiratory arrest, chest pain, horizontal ST-segment depression > or =1 mm on the electrocardiogram in any lead, symptomatic hypotension), or (3) other intravenous dipyridamole-induced side effects (persistent headache, dizziness, flushing, nausea, dyspnea, and ischemic chest pain) or anginal equivalent. The protocol properly identified patients with impaired pulmonary function. There was no difference in the frequency of adverse marked events among groups A, B, or C (1 % vs 4% vs 2%, p = 0.25). Patients in group A had more minor side effects than those in group B (53% vs 35%, p = 0.004). Specifically, patients in group A were more likely to wheeze (39% vs 1 %, p = <0.001), but wheezing in group A was self-limited or responded to treatment as described in the protocol. The prevalence of positive thallium-201 scans in group A (44%) compared with group C (49%) was not different (p = 0.15). CONCLUSIONS: A nurse-administered risk assessment and pretreatment protocol (1) properly identified patients with impaired pulmonary function, (2) permitted completion of intravenous dipyridamole testing in patients at risk for bronchospasm without an increased incidence of marked adverse events, and (3) did not appear to influence the interpretation of the thallium test.

Left ventricular dysfunction in deteriorating patients with chronic obstructive pulmonary disease.

OBJECTIVE: To evaluate the effectiveness of simple clinical variables and radionuclide ventriculogram in separating those patients with isolated chronic obstructive pulmonary disease (COPD) from those with COPD and coexisting left ventricular dysfunction (LVD). DESIGN: Retrospective record review of 77 patients with increasing dyspnea, defined as recent deterioration in exercise tolerance, new use of corticosteroids, or recent hospital admission for COPD; referred to the outpatient Pulmonary Rehabilitation Program at the Cincinnati Veterans Affairs Medical Center from July 1987 to October 1992. SETTING: Outpatient medical clinic. PATIENTS: Veterans who were referred to the Pulmonary Rehabilitation Program. MEASUREMENTS: History and physical findings, pulmonary function tests, arterial blood gases, distance achieved in a 12-min walk, dyspnea score, electrocardiogram, chest radiograph, and radionuclide multigated ventriculography. RESULTS: Twenty-five of 77 patients evaluated in the Pulmonary Rehabilitation Program for increasing dyspnea were functionally more limited (12-min walk 10.4 vs 13.9 laps; MRC score 2.68 vs 2.06; p < 0.05) and had left ventricular dysfunction (LVD) (left ventricular ejection fraction < 40%) associated with wall motion abnormalities on radionuclide ventriculogram. Careful standard clinical evaluation did not separate those patients with COPD from those with both COPD and LVD. CONCLUSIONS: LVD was found in 32% of patients with COPD presenting with symptomatic deterioration. Since the therapeutic approach to these two disorders differs, the identification of patients with LVD is important. Prospective studies are needed to identify the most cost-effective approach to this problem of coexisting disease and to evaluate the benefit from therapy.

Studies on the mechanism of decreased neutrophil adherence to postconfluent cultured endothelial cells.

The adherence of neutrophils (PMN) to endothelium is a crucial early step in neutrophil-mediated vascular injury. However, vascular injury is not a necessary event in inflammatory states, which suggests that endogenous mechanisms may protect endothelial cells from neutrophil-mediated injury. Previous studies suggested that leukocytes adhered in greater numbers to vascular endothelium in vivo and in vitro, where the contiguity of the cells was disrupted and where endothelial cells were actively migrating and proliferating. We studied the effect of development of a confluent monolayer on adherence of human PMN to cultured bovine calf aortic endothelial cells and investigated several mechanisms by which this effect might occur. We found that adherence of quiescent and activated PMN decreased with development of a confluent endothelial cell monolayer. A similar effect was found using human umbilical-vein endothelial cells. In contrast, adherence of nylon wool-nonadherent, thymus-derived lymphocytes increased. Variation in neutrophil adherence was not due to adherence of PMN to exposed tissue culture plastic or to exposed matrix components in preconfluent cultures, nor due to products released into culture supernatants. Diminished PMN adherence to postconfluent monolayers may have been related to changes in endothelial cell glycoproteins because neuraminidase or cycloheximide pretreatment augmented PMN adherence to postconfluent cultures more than to preconfluent cultures. However, the extent of total cell surface sialation, as assessed by neuraminidase-releasable [3H]glucosamine from metabolically labeled monolayers, did not differ between pre- and postconfluent cultures, suggesting that some specific sialated cell surface constituent is responsible for decreased PMN adherence to postconfluent monolayers.(ABSTRACT TRUNCATED AT 250 WORDS)