Driving Organizational Change From the Bedside: The AACN Clinical Scene Investigator Academy.

BACKGROUND: Staff nurses are pivotal in leading change related to quality improvement efforts, although many lack skills to steer change from the bedside. The American Association of Critical-Care Nurses (AACN) staff nurse leadership program, Clinical Scene Investigator (CSI) Academy, teaches and empowers staff nurses in leadership skills and change concepts to translate evidence into practice affecting patient outcomes. OBJECTIVES: To describe the curriculum of the AACN CSI Academy that provides staff nurses with the leadership skills required to create unit-based change projects that positively impact patient/family outcomes. METHODS: The curriculum of the Academy included leadership topics, communication, change concepts, quality improvement methods, project management, and data management and analysis. Each team of participants collected project data to show improvements in patient care. The program evaluation used many data sources to assess the program effectiveness, relating to the professional growth of the participant nurses. The participants assessed project patient outcomes, sustainability, and spread. RESULTS: The first cohort of CSI participants included 164 direct care nurses from 42 hospitals in 6 cities. They rated the Academy highly in the program evaluation, and they reported that the Academy contributed to their professional development. The individual hospital quality improvement projects resulted in positive patient and estimated fiscal outcomes that were generally sustained 1 year after the program. CONCLUSION: With the skills, tools, and support obtained from participation in the CSI Academy, staff nurses can make substantial contributions to their organizations in clinical and possibly fiscal outcomes.

Journey of Excellence: Implementing a Shared Decision-Making Model.

Research has shown that nurses who participate in shared decision making (SDM) have more control over their practice and greater job satisfaction, and hospitals that have instituted SDM have lower rates of nurse turnover and better patient outcomes. The purpose of this article is to describe the implementation of an SDM structure at a pediatric hospital. The hospital's chief nurse officer charged a group of nurses with developing SDM guidelines to outline the purpose, structure, and function of unit councils. A targeted, multifaceted approach to the implementation of these guidelines led to the successful standardization of nine existing unit councils and the expansion of the SDM unit council structure to all other hospital units. Work continues with guideline refinement in response to the real-life circumstances nurses encounter on the units, and the original group of nurses continues to review literature on SDM best practices. In addition, professions other than nursing, including multidisciplinary teams in dialysis, cardiovascular surgery, respiratory therapy, and child life, have adopted the guidelines for use in their departments.

Apoptotic-related protein expression in the diaphragm and the effect of dopamine during inspiratory resistance loading.

Dopamine (DA) is a free radical scavenger that attenuates apoptosis. We studied the effects of normal saline (NS) and DA on diaphragm apoptotic protein expression following 60 min of inspiratory resistance loading in rats. We tested for 27 apoptotic-related proteins and found 12 in the diaphragm. Of the 12 proteins, superoxide dismutase copper zinc (SOD [CuZn]) and proprioceptive event related potential (PERP) were significantly higher in the DA group than in the NS and sham groups (p = .002, p = .007). DA group diaphragms had significantly greater expression of SOD (CuZn) than the NS (p = .005) and sham group diaphragms (p = .003). Likewise, the DA group had significantly greater expression of PERP than the NS group (p = .008). These results suggest that DA decreases diaphragm apoptosis through elevated expression of SOD (CuZn). The identification of 12 apoptotic-related proteins will assist investigators as they study diaphragm apoptosis.

Dopamine alleviation of diaphragm contractile dysfunction and reduction of deoxyribonucleic acid damage in rats.

BACKGROUND: Weaning difficulties from mechanical ventilation are associated with diaphragm fatigue and reduced respiratory muscle endurance capacity. Often the work of breathing is increased during the weaning process as a result of inspiratory resistance loading (IRL). IRL produces increased free radical formation that contributes to deoxyribonucleic acid (DNA) damage. The purpose of this study was to determine whether dopamine reduced nuclei DNA damage when the work of breathing was increased. We hypothesized that the administration of low-dose dopamine (2 microg/kg/min) during IRL decreases myonuclei DNA damage associated with free radical formation. METHODS: In this in vivo study, 30 male Sprague-Dawley rats were divided into three groups: (1) the sham group receiving no IRL or no intravenous fluids, (2) IRL with administration intravenous saline, and (3) IRL with intravenous low-dose dopamine (2 microg/kg/min). All rats from the same breed and similar colonies were purchased from one laboratory facility to ensure homogeneity. The animals were anesthetized and tracheotomized, and an ultrasonic sensor was attached to the right hemidiaphragm to measure diaphragm shortening. Diaphragm fatigue was produced by IRL. Dopamine (2 microg/kg/min) was infused intravenously before and during loading. The diaphragms were excised, and myonuclei DNA damage was measured using the fluorescent dyes ethidium bromide and acridine orange and comet analyses as indices of free radical injury. RESULTS: In rats receiving saline, diaphragm shortening decreased by 37% after 45 minutes of IRL (P = .002) compared with baseline. In contrast, rats infused with dopamine exhibited a 31% increase in diaphragm shortening after 45 minutes of IRL (P = .037). With the use of differential dye uptake, in the saline group 59% of the nuclei were apoptotic, and 18% were necrotic. However, in the dopamine group there was significantly less apoptotic nuclei (16%, P < .001) and necrotic nuclei (7%, P = .005). Myonuclei DNA damage, measured by comet analyses, was associated with tail length and tail olive moment, which were 37% and 60% greater, respectively, in the saline group than in the dopamine group (P < .05). CONCLUSION: These data support the hypothesis that low-dose dopamine during IRL reduced myonuclei DNA damage as measured by the fluorescent dyes and comet analysis. In addition, diaphragm fatigue was prevented by the administration of dopamine during IRL.

Ventilator-associated pneumonia improvement program.

Ventilator-associated pneumonia (VAP) is a significant clinical problem associated with increased intensive care unit and hospital length of stay and substantial increases in delivery cost and associated morbidity and mortality. With system changes and management of the environment of care, the incidence of VAP was reduced in seven of our intensive care units across the system. Steps necessary to reduce VAP were identified and put into place in all the intensive care units. Patient positioning, oral care, nutrition, and management of comfort drugs are a few of the processes addressed to reduce VAP. Standardization of these essential care practices can reduce the incidence of this nosocomial infection and its associated increases in the cost of care delivery and mortality.

Effect of dopamine on rat diaphragm apoptosis and muscle performance.

The purpose of this study was to determine whether dopamine (DA) decreases diaphragm apoptosis and attenuates the decline in diaphragmatic contractile performance associated with repetitive isometric contraction using an in vitro diaphragm preparation. Strenuous diaphragm contractions produce free radicals and muscle apoptosis. Dopamine is a free radical scavenger and, at higher concentrations, increases muscle contractility by simulating beta2-adrenoreceptors. A total of 47 male Sprague-Dawley rats weighing 330-450 g were used in a prospective, randomized, controlled in vitro study. Following animal anaesthetization, diaphragms were excised, and muscle strips prepared and placed in a temperature-controlled isolated tissue bath containing Krebs-Ringer solution (KR) or KR plus 100 microm DA. The solutions were equilibrated with oxygen (O2) at 10, 21 or 95% and 5% carbon dioxide, with the balance being nitrogen. Diaphragm isometric twitch and subtetanic contractions were measured intermittently over 65 min. The diaphragms were then removed and, using a nuclear differential dye uptake method, the percentages of normal, apoptotic and necrotic nuclei were determined using fluorescent microscopy. There were significantly fewer apoptotic nuclei in the DA group diaphragms than in the KR-only group diaphragms in 10 and 21% O2 following either twitch or subtetanic contractions. Dopamine at 100 microm produced only modest increases in muscle performance in both 10 and 21% O2. The attenuation of apoptosis by DA was markedly greater than the effect of DA on muscle performance. Dopamine decreased diaphragmatic apoptosis, perhaps by preventing the activation of intricate apoptotic pathways, stimulating antiapoptotic mechanisms and/or scavenging free radicals.

Pressure-support ventilation and diaphragm shortening in the rat model.

Little is known about how pressure-support ventilation affects diaphragm performance because there is no direct measurement of diaphragm function in the clinical setting. An indicator of diaphragm performance or work is the product of diaphragm muscle shortening and intrathoracic pressure during inspiration. We studied the effect of pressure-support ventilation on diaphragm shortening, diaphragm work, and other cardiopulmonary parameters. In 15 anesthetized Sprague-Dawley male rats, pressure support was increased from 0 to 10 cm H2O in 2 cm increments. Increasing pressure support from 0 to 10 cm H2O resulted in respiratory rate decreasing 25%, tidal volume increasing 148%, minute ventilation increasing 91%, end-tidal carbon dioxide decreasing 5%, and cardiac output decreasing 30%. Progressively increasing pressure support to 10 cm H2O was accompanied by decreases in the end-inspiratory pressure without significant increases in diaphragm shortening. Therefore, diaphragm work was decreased. The lack of an increase in diaphragm shortening in the presence of an increase in tidal volume indicated that there was an augmentation of thoracic volume in the coronal and/or horizontal axes instead of the cephalocaudal axes throughout inspiration. These findings may be useful to nurse anesthetists in the understanding of diaphragm work when patients are being ventilated with pressure-support ventilation.

Comparison of a visual to a computer-assisted technique for detecting apoptosis.

In many studies, fluorescent dyes (ethidium bromide [EB] and acridine orange [AO]) are used to stain DNA to determine if nuclei are apoptotic. However, there are numerous visual methods for counting these stained DNA that may lead to inaccuracies Measuring apoptosis by the visual counting method may be imprecise because of the variability of individuals' perception of color. Therefore, the authors compared a visual method of counting chromatin for apoptosis with a method relying on a computer program. They began counting chromatin using the visual method, in which individuals identify the stained DNA using their own visual perception. For comparison, they used a software-based counting method (analySIS software) to determine the color (hue) of the stained DNA. Using the numeric hue values from the software eliminates the variations in human color perception. Intra and interrater reliability of the visual and computer-assisted counting methods were evaluated with Spearman's. The authors found statistical significance in the intrarater reliability (r = 1.0, P = 0.0001 for all chromatin categories) and interrater reliability (r = 0.975, P = 0.005 for both readings) when using the software program. No statistical significance was found for the visual counting method, indicating inaccuracy between and within raters. Thus, the computer-assisted counting method of identifying the damaged DNA is more accurate and precise than the individual's visual perception of color. Based on these data, apoptosis measurements using color staining with EB and AO should be determined using hue values generated by a computer program and not by a researcher's visual assessment.

Oxidative stress in critically ill patients.

Oxygen-derived free radicals play an important role in the development of disease in critically ill patients. Normally, oxygen free radicals are neutralized by antioxidants such as vitamin E or enzymes such as superoxide dismutase. However, in patients who require intensive care, oxygen free radicals become a problem when either a decrease in the removal or an overproduction of the radicals occurs. This oxidative stress and the damage due to it have been implicated in many diseases in critically ill patients. Many drugs and treatments now being investigated are directed toward preventing the damage from oxidative stress. The formation of reactive oxygen species, the damage caused by them, and the body's defense system against them are reviewed. New interventions are described that may be used in critically ill patients to prevent or treat oxidative damage.