Temperature measurement in critically ill adults: a comparison of tympanic and oral methods.

BACKGROUND: Despite increasing use of tympanic thermometers in critically ill patients who do not have a pulmonary artery catheter in place, variations in measurements obtained with the thermometers are still a problem. OBJECTIVE: To compare the range of variability between tympanic and oral electronic thermometers. METHODS: Subjects were a convenience sample of 72 patients admitted to a 24-bed adult medical-surgical intensive care unit. For each patient, temperatures were measured concurrently (within a 1-minute period) with an oral (Sure Temp 678) thermometer, a pulmonary artery catheter (Baxter VIP Swan-Ganz Catheter), and 2 tympanic (FirstTemp Genius II and ThermoScan Ear Pro-1) thermometers. Each subject was used up to 3 times for data collection. Measurements obtained with the oral and tympanic thermometers were compared with those obtained with the pulmonary artery catheter. Nonparametric analysis of data was used. RESULTS: The magnitude of error for the ThermoScan tympanic thermometer differed significantly from that of the Genius II tympanic thermometer and the SureTemp oral thermometer (P < .001). Application of the Bland and Altman method to frame the data on the basis of an accuracy tolerance zone of +/-0.5 degrees C indicated variability with both the oral and tympanic methods. The overall degree of variability was lower for the oral thermometer. CONCLUSIONS: Oral thermometers provide less variable measurements than do tympanic thermometers. Use of oral thermometry is recommended as the best practice method for temperature evaluation in critical care patients when measurement of core temperature via a pulmonary artery catheter is not possible.

A quality-improvement approach to meeting the needs of critically ill patients and their families.

Family support can have positive effects on critically ill patients, so limiting visitation in critical care units may not be in patients' best interests. This study looked at increasing visitation using a quality-improvement model.

Families first.

Family support can have positive effects on critically ill patients, so limiting visitation in critical care units may not be in their best interest. This study examined the outcomes of increasing visitation using a quality-improvement model.

Temperature measurement in critically ill orally intubated adults: a comparison of pulmonary artery core, tympanic, and oral methods.

OBJECTIVE: Core temperature measurement using a pulmonary artery (PA) catheter is considered the gold standard for measuring temperatures in critically ill patients. The objective of this study was to compare oral and tympanic temperature measurements (in both the oral and core equivalence modes) against PA core temperature measurements to determine which method was the most accurate and reliable in the absence of a PA catheter. DESIGN: Prospective, descriptive comparative analysis. PATIENTS: Convenience sample of 102 critically ill orally intubated patients with a PA catheter in place. SETTING: A 24-bed medical/surgical/trauma intensive care unit in a university-affiliated medical center. INTERVENTIONS: Four experienced intensive care unit nurses were trained in the use of temperature measurement with the oral, tympanic (both core and oral equivalence modes were used), and PA core methods. Simultaneous temperature measurements were then taken once in each subject using each method. The potential covariates that were analyzed were mean blood pressure, patient acuity using the Simplified Acute Physiology Score II, age, sex, ambient room temperature, and ventilator circuit temperature. MEASUREMENTS AND MAIN RESULTS: The training period indicated that it took more time to train experienced nurses in the use of tympanic thermometry than oral thermometry. Descriptive statistics were the following: core, x = 37.33 (SD = 0.89); oral, x = 37.18 (SD = 0.92); tympanic oral, x = 36.80 (SD = 0.93); and tympanic core, x = 37.12 (SD = 1.0). Bias averages were calculated and were significantly different from 0 for all three methods (oral-PA core, -0.15 [SD = 0.36]; tympanic core-PA core, -0.11 [SD = 0.57], tympanic oral-PA core, -0.52 [SD = 0.53]), indicating that there is some degree of decreased accuracy associated with each method when compared with PA core. However, scatter plots using the Bland and Altman methodology (Altman DG, Bland JM: Practical Statistics for Medical Research. London, Chapman and Hall, 1991) illustrate that the greatest variability is associated with the tympanic method. CONCLUSIONS: Temperature measurement is an important piece of clinical data in a critically ill patient population. We found oral thermometry to be the most accurate and reproducible method when a PA core measurement was not available.

Transplant issues: infections and immunosuppressant drugs.

Patients who have had organ transplants are at risk for infection and organ rejection. Critical care nurses can improve patient outcomes by recognizing and treating infection and by familiarizing themselves with the immunosuppressant medications used in transplantation.

Implementation of a pet visitation program in critical care.

We have no quantitative research data to document that these visits are actually helpful to patients in any measurable way, although we certainly hope to have some soon. However, observations of staff members and evaluations from participants in the program have been quite positive thus far. The program has been in place for more than 2 years, and about 30 pets have visited so far, including 28 dogs and 2 cats. Implementing a pet visitation program for critically ill patients affords healthcare providers the opportunity to offer a unique and humanistic therapeutic intervention to appropriate patients. Although it is a time-consuming endeavor, it has been well received by those patients and families that have participated in pet visits. Critically ill patients are often denied many simple pleasures because they are in physiological crisis. Such patients experience loneliness, isolation, depression, and lack of emotional support. Pet visitation is one way to address these common problems of ICU patients. For this reason, pet visitation will remain a therapeutic option for the support of our critically ill patients.

Evidence-based practice and the role of nursing leadership.

A new term, evidence-based practice, is beginning to appear both in the healthcare literature and at professional, conferences. Its meaning, however, is not always clear, nor is its full implication for nurse administrators explained. This article provides a pragmatic definition of evidence-based practice developed in the nursing division at Baystate Medical Center, Springfield, Massachusetts. It outlines steps required to institutionalize evidence as a routine part of nursing practice and provide examples of its use.

Renal replacement therapy in critical care: implementation of a unit-based continuous venovenous hemodialysis program.

Implementing a program as complex as continuous venovenous hemodialysis without the involvement of nephrology nurses is a challenge. However, with proper planning, appropriate staff support, and the ability to make changes as implementation proceeds, a successful program can be developed. Our reward is that we are now able to offer a therapy that is important and potentially lifesaving to those critically ill patients with renal failure who are unable to tolerate intermittent hemodialysis.

Influence of port site on central venous pressure measurements from triple-lumen catheters in critically ill adults.

BACKGROUND: Measurements of central venous pressure are generally obtained through one of the three ports of centrally placed triple-lumen catheters. However, no scientifically based literature is available that guides clinical practice and indicates which of the lumens is most appropriate for obtaining these measurements. OBJECTIVE: To determine if a difference exists between measurements of central venous pressure obtained via the proximal, medial, and distal ports of a triple-lumen catheter. METHODS: Measurements of central venous pressure in 48 adult ICU patients were obtained via each of the three ports of a triple-lumen catheter. Catheters were placed in either the right or left subclavian vein or the right or left internal jugular vein. The flush system was single-transducer, trifurcated pressure tubing system. Data were evaluated for variation among the three ports of the catheter for readings taken at a single point. RESULTS: A repeated-measures analysis of variance showed significant differences across port sites. Post hoc univariate F tests showed significant differences between the proximal and distal ports and between the medial and distal ports. In some patients, the difference between central venous pressure obtained from the distal port and pressure obtained from the proximal or the medial port may be clinically significant. CONCLUSION: Because measurements of central venous pressure may not always be comparable for all three ports of a triple-lumen catheter, care should be taken to distinguish when changes in pressure readings are a result of a change in port site rather than in the patient's condition.

Strengthening the in-hospital chain of survival with rapid defibrillation by first responders using automated external defibrillators: training and retention issues.

STUDY OBJECTIVE: To determine whether staff outside critical care areas who were proficient in basic life support (BLS) could be easily trained to use automated external defibrillators (AEDs) and whether they would retain these skills. DESIGN: Prospective, longitudinal cohort series. SETTING: Two university teaching hospitals. PARTICIPANTS: One hundred forty nurses who had previously learned BLS and constituted the staff from three medical/surgical nursing units from each study hospital. INTERVENTIONS: The nurses were taught how to use the Heartstart 1000s, a lightweight portable shock-advisory AED, in a 2-hour class with an instructor and manikin-to-student ratio of 1:5. The course emphasized hands-on practice of the BLS-AED algorithm on a computerized manikin. RESULTS: Using a similar scenario, each nurse was evaluated on the computerized manikin immediately after training (posttest). At 1 to 3, 4 to 6, and 7 to 9 months after the initial training, convenience samples of the cohort in three different groups were evaluated for retention. Satisfactory performance was defined as delivery of the first AED shock within 2 minutes of recognition of the arrest. At the posttest after training, 139 of 140 nurses (99%) demonstrated satisfactory performance. Of 77 nurses evaluated, 31 of 32 at 1 to 3 months, 18 of 18 at 4 to 6 months, and 24 of 27 at 7 to 9 months after initial training (95% overall) performed satisfactorily. CONCLUSION: As has been demonstrated with prehospital emergency personnel, nurses outside critical care areas who are proficient in BLS can easily learn and retain the knowledge and skills to use AEDs. Automated external defibrillation, a BLS skill, should be incorporated into BLS programs (BLS-AED) for all hospital personnel expected to respond to a patient in cardiac arrest, with rapid defibrillation taking priority over CPR.