Critical appraisal tools facilitate the work of the quality professional.

Quality management activities involve the application of scientific principles to performance improvement activities. With the plethora of available information, a systematic approach to evaluating the quality and usefulness of sources is necessary. One approach is critical appraisal, which is used to search for the best evidence or integrate evidence with clinical expertise. Two critical appraisal tools (CATs) are presented here, the first for any original clinical or health services research study and the second for research synthesis. The CAT scoring system and summaries of reviewed references facilitate understanding of the "state of the science" in the areas of interest.

Burn patients' pain and anxiety experiences.

The purpose of this study was to examine burn patients' pain and anxiety experiences during resting conditions and procedures. The relationship of contextual factors and interventions to pain and anxiety were also explored. Procedural pain was significantly higher than resting pain (P = .02); however, there were no significant differences in anxiety between resting conditions and procedures (P = .16). There was a significant difference between burn patients' acceptable level of pain, resting pain, and procedural pain (P = .01). Resting pain was significantly lower than patients' acceptable level of pain (P = < .01). Procedural pain was slightly lower than patients' acceptable level of pain, but these results were not statistically significant (P = .37). Percent of total body surface burned was associated with increased procedural anxiety (P = .022). Family presence correlated with decreased procedural pain (P = .011) and midazolam use (P = .047). Prior experience with the procedure was associated with increased morphine(P = .003) and midazolam use (P = .029). These findings support the multifactorial nature of burn pain and anxiety and provide guidance for practice.

Analysis of factors related to the development of ventilator-associated pneumonia: use of existing databases.

OBJECTIVE: To investigate factors related to ventilator-associated pneumonia to assist in the development and implementation of prevention strategies. METHODS: A retrospective, descriptive design was used. Power analysis determined sample size. A consecutive sample of 120 patients admitted to the critical care units of a level I trauma center who were receiving mechanical ventilation was used. Data were obtained from clinical and financial databases. Variables included demographic data, causative organism of the pneumonia, medications, comorbid conditions, complications, duration of therapies, length of stay, and cost per case. RESULTS: The average patient was a 49-year-old man. The sample was 54.9% trauma patients, and the prevalence of ventilator-associated pneumonia was 16.7%. Significant factors included duration of intubation (r = 0.28, P = .005), mechanical ventilation (r = 0.26, P = .005), and tube feeding (r = 0.30, P = .001); trauma (phi = 0.24, P = .009); and use of histamine2 receptor antagonists (phi = -0.25, P = .006). The only variable that significantly increased the odds ratio for ventilator-associated pneumonia was trauma. The only variable that significantly decreased the odds ratio was use of histamine2 receptor antagonists. Patients in whom ventilator-associated pneumonia developed had a 16-day increase in length of stay (t = -2.68, P = .008), and a $29,369 increase in cost per case (t = -3.649, P = .000). CONCLUSIONS: These findings provide a baseline for discussions about potential changes in practice to help prevent ventilator-associated pneumonia.

Noninvasive positive-pressure ventilation: averting intubation of the heart failure patient.

Mechanically ventilating patients with heart failure who have respiratory distress can increase hospital costs, complications, and mortality. A few studies have evaluated the use of noninvasive positive-pressure ventilation (NPPV) as an alternative treatment for these patients. This article describes NPPV and reviews its use in managing an acute exacerbation of heart failure.

Venipuncture versus central venous access: a comparison of methotrexate levels in pediatric leukemia patients.

Patients receiving methotrexate (MTX) therapy for treatment of acute lymphocytic leukemia (ALL) consistently have venipuncture MTX levels drawn twice during each hospitalization. The purpose of this study was to compare MTX levels drawn from central venous catheters (CVCs) with those drawn by venipuncture. A convenience sample of 14 pediatric patients was used, with a total of 33 peak levels and 33 trough level sample pairs collected. Venipuncture and CVC levels were compared by using the paired t-test and analyzing the peak and trough data pairs separately. Results confirmed there was no difference in MTX level results (peak, p = .502; trough, p = .114). However, the CVC trough levels would have changed clinical management for 5 of the 33 patients. Therefore, it is recommended that all MTX levels be drawn from the CVC but that trough MTX levels that would alter clinical management be verified by a venipuncture sample. This method will safely minimize the number of venipunctures for children with ALL.

Demonstrating the value of the advanced practice nurse: an evaluation model.

Advanced practice nurses are challenged to assess comprehensively the value of their role and the impact of their practice. Value is defined as quality divided by cost. The correlations among the structure, strategies of care (process), and their objectives (outcome) are key to the assessment of the quality of care and the impact of the advanced practice nurse's role. Advanced practice nurses are challenged to provide high quality care for a competitive or decreased cost. For the profession of nursing, outcomes are the result of interventions based on the nurse's clinical judgment and theoretical, practical, or scientific knowledge. An evaluation model is presented that comprehensively measures the impact of advanced practice nurses on patients and families, and an example is presented. Using the model will give credibility and validity to the APNs' positive impact on the quality and financial outcomes of care for each patient and for entire patient populations.

Application of a transactional model of stress and coping with critically ill patients.

Critically ill patients are exposed to many physiologic and environmental stressors, which can result in deleterious physiological and psychological effects. Stress and coping within Lazarus and Folkman's transactional model is used as a basis for describing patient responses in critical care. The authors propose specific strategies to reduce stress and maximize coping in the critically ill patient.

CORE characteristics for survival in patient care redesign.

As patient care delivery systems evolve and facility redesign occurs, innovative models of care delivery require clinicians to possess certain qualities for successful implementation of redesign efforts. Certain specific "CORE" abilities are key for all clinicians. They are: C: the ability to think critically, communicate, and collaborate with patients, families, and other health care team members. O: the need to be outcome-oriented, that is, striving to optimize patient and family outcomes along the continuum. R: realization of the value of research and the ability to use research resources to develop and evidence-based practice. E: the ability to keep abreast of a wide variety of clinical and other health care-related topics. Demonstration of these CORE abilities will increase a clinician's opportunity to achieve professional success into the 21st century.

Holistic acute care units: partnerships to meet the needs of the chronically ill and their families.

The traditional acute care health care environment does not meet the needs of chronically ill patients and their families. The classic paternalistic approach encourages dependence on the health care team. This report reviews several innovative types of patient care delivery models, including patient-focused care, family-centered care, cooperative care, and Program Planetree. The core concepts of these various models are described and compared. Related research is presented. A synthesis of these existing models to meet the needs of chronically ill medical patients holistically is proposed. The implementation of the holistic model with chronically ill patients and their families is depicted.

Effect of a music intervention on noise annoyance, heart rate, and blood pressure in cardiac surgery patients.

BACKGROUND: Exposure to noise in a critical care unit may trigger a response by the sympathetic nervous system, thereby increasing cardiovascular work in patients recovering from cardiac surgery. OBJECTIVE: To investigate the effects of a music intervention given twice on the first postoperative day on noise annoyance, heart rate, and arterial blood pressure in subjects with high (n = 22) and low (n = 18) sensitivity to noise. METHODS: A prospective, quasi-experimental, repeated-measures design was used. Based on results of power analysis, the sample size was 40. Subjects were recruited preoperatively, and their sensitivity to noise was assessed. On the first postoperative day, repeated-measures data were collected on levels of noise annoyance and physiological variables during 15 minutes of baseline and 15 minutes of music intervention on two occasions. Subjects completed a follow-up questionnaire regarding their perceptions of the noise in the critical care unit and the music intervention. RESULTS: Repeated-measures analysis of variance showed that subjects had lower levels of noise annoyance during music intervention than at baseline. Heart rate and systolic blood pressure decreased during the music intervention compared with baseline. Diastolic blood pressure decreased during the music intervention from baseline during time 2, but not time 1. Subjects with high baseline scores of noise sensitivity preoperatively had higher baseline levels of noise annoyance in the critical care unit the first postoperative day. Subjects rated the music intervention as highly enjoyable regardless of their baseline noise sensitivity or noise annoyance. CONCLUSION: Results of this study support the idea that noise annoyance is a highly individual phenomenon, influenced by a transaction of personal and environmental factors. Use of a music intervention with cardiac surgery patients during the first postoperative day decreased noise annoyance, heart rate, and systolic blood pressure, regardless of the subject's noise sensitivity.

Nurses' attitudes toward patient and family education: implications for clinical nurse specialists.

This study had two purposes: (1) to examine nurses' attitudes toward patient and family education; and (2) to identify issues, barriers, and concerns related to patient and family education. A three-part survey was distributed to licensed nurses employed in a large healthcare system in Central Florida. Analysis of variance with posthoc multiple comparisons found differences in responses between different demographic groups. A model for meeting the patients' and families' education needs is proposed, using the various roles of the clinical nurse specialist to facilitate the process.

Acute burn injury: a trauma case report.

Acute major burn injury provides the critical care nurse with a dynamic and complex patient care challenge. Understanding the physiological processes associated with acute major burn injury allows for proactive assessment and interventions. A thorough knowledge base regarding acute burn injury facilitates optimal patient care and improves the probability of a quality patient outcome.

Local and systemic effects of major traumatic wounds.

Major traumatic wounds cause a chain of complex localized and systemic events. Understanding these physiologic processes, potential complications, and treatment priorities can assist the nurse in facilitating wound healing and optimizing patient outcomes.

Usefulness of measures of Svo2, Spo2, vital signs, and derived dual oximetry parameters as indicators of arterial blood gas variables during weaning of cardiac surgery patients from mechanical ventilation.

OBJECTIVES: To determine whether combined use of the parameters of mixed venous oxygen saturation, arterial oxygen saturation obtained by pulse oximetry (Spo2), and vital signs correlated with arterial blood gas variables (ABGs) better than each individual variable during weaning of postoperative cardiac surgery patients from mechanical ventilation; and to evaluate the relationship of derived parameters: oxygen extraction index and ventilation/perfusion index (VQI), and ABGs. DESIGN: Secondary analysis of previous correlational study. SETTING: The cardiac care unit in a large medical center in central Florida. PATIENTS: Thirty postoperative coronary artery bypass graft patients being weaned from mechanical ventilation. METHODS: After a change in ventilator settings during systematic weaning towards extubation, measurements of variables were taken during a 30-minute period. At 30 minutes, an ABG was drawn for comparison. Data were collected after two ventilator changes. A total of 57 data sets were used for analysis. RESULTS: By use of multiple regression analyses, statistically significant (p < 0.01) independent variables predicting pH and partial pressure of carbon dioxide were Spo2 and respiratory rate. The independent variable contributing to the model versus partial pressure of oxygen was Spo2. The oxygen extraction index did not correlate with ABGs; however, the VQI correlated significantly with all ABG variables except bicarbonate. CONCLUSIONS: The use of multiple parameters was no more useful in predicting ABGs than individual variables of Spo2 and respiratory rate. The derived VQI parameter correlated with ABGs. The use of VQI in conjunction with Spo2 and respiratory rate may assist in patient monitoring during weaning and reduce the number of ABGs needed.

Chronotherapy in acutely ill patients with respiratory disorders: Part I. Respiratory chronobiology and chronopathology.

Chronotherapy is a relatively new approach in patient care that is based on knowledge of the various biologic rhythms of the body. Treatment is aimed at supporting normal rhythms or altering therapies based on known variations in body rhythms. Application of chronotherapy concepts to the pathology of respiratory diseases is discussed to provide a basis for altering pharmacologic therapy in the care of critically ill patients with respiratory disorders.

Chronotherapy in acutely ill patients with respiratory disorders: part II. Application of chronopharmacology in patient care.

Tailoring medication administration to obtain the optimal chronobiologic function of individuals with respiratory disorders has been studied by numerous researchers. Integration of chronobiologic concepts into therapeutic regimens for patients with chronic airflow obstruction has been successful in reducing nocturnal symptoms of reduced airflow. Application of chronotherapeutic concepts in administration of commonly used respiratory medications is presented. Pharmacologic and nonpharmacologic chronotherapeutic implications for providing care for critically ill patients with respiratory disorders are discussed.

Comparison of SVO2, SpO2, and clinical parameters with arterial blood gases during ventilatory weaning after cardiac surgery.

Correlations of mixed venous and arterial oxygen saturation, heart rate, respiratory rate, and mean arterial pressure with arterial blood gas variables were computed for 57 sets of data obtained from 30 postoperative coronary artery bypass graft patients who were being weaned from mechanical ventilation. Arterial oxygen saturation and respiratory rate correlated significantly, although moderately, with blood gases.

The use of aspirin in cardiovascular disease.

Aspirin has many uses in cardiovascular disease. It is used for primary prophylaxis; as an adjunctive therapy in angina, acute myocardial infarction, and thrombolytic therapy; and to promote vessel patency after angioplasty and coronary artery bypass grafting. This article reviews the recent research findings on the use of aspirin in cardiovascular disease and discusses remaining questions and nursing implications.