Pregnant mothers out of the perinatal regionalization's reach.

INTRODUCTION: Birth of very low birth weight (VLBW) infants outside subspecialty perinatal centers increases risk for death and major morbidities. OBJECTIVE: The purpose of this study is to evaluate barriers to utilizing a regional perinatal center for the birth of VLBW infants to mothers not living in the immediate vicinity of the center. METHODS: We conducted a retrospective cohort study of VLBW infants residing in the catchment area of a community level II, Specialty Neonatal Unit (SN) admitted to a Regional Subspecialty Neonatal Intensive Care Unit (RC) between January 1999 and December 31, 2004. Maternal demographics and prenatal care as well as outcomes were compared by place of birth. RESULTS: Out of 98 VLBW infants admitted to the RC, 49 (50%) were delivered outside the RC (out-born) and 49 (50%) were born at the RC (in-born). There was no statistical difference in insurance coverage, race, gestational age, severity of illness or maternal demographic factors between out-born and in-born infants. Less than adequate prenatal care rather than distance of maternal residence from the RC was associated with birth outside the RC. Adjusting for prenatal care, distance of residence from the RC increased the risk for delivering outside the center in the subset of mothers insured by Medicaid. CONCLUSIONS: Mothers of VLBW infants who received less than adequate prenatal care and did not live in the vicinity of a subspecialty center had an increased risk for delivery outside that center compared to those with adequate care. Appropriate place of birth for VLBW infants to low-income mothers may be influenced by the distance of their residence to an RC.

Considerations in measuring the electrical potentials of metallic restorations in vivo.

Many variables are believed to affect the accurate measuring of metallic restoration electrical potentials. This study examined the effects of intra- versus extra-oral location of the reference electrode, the type of metallic probe used to make contact with the restoration, and scratching and brushing of the restoration surface. Dental amalgam restorations were measured in 40 human subjects. Results showed that only the location of the reference electrode affected the central tendency of the potential. The study discusses the significance of some experimental variables in the accurate measuring of metallic potentials and the need to consider individual subject differences when statistically analysing for the central tendency of a sample.

Saline for peripheral intravenous locks in neonates: evaluating a change in practice.

PURPOSE: To evaluate the efficacy of saline versus 10 units/ml heparin for peripheral i.v. flushes in neonates. DESIGN: A nonexperimental group design was used to compare the longevity of heparin and saline i.v. locks. A research utilization method was chosen to increase the study power while simultaneously implementing a practice change and evaluating the outcomes. Power analysis showed that a sample size of approximately 120 per group was needed to decrease the risk of beta error to 0.1. SAMPLE: Subjects included neonates in the Special Care Nurseries at a Level III large midwestern university teaching hospital. Data were collected from a convenience sample of 123 neonates receiving 10 units/ml heparin flush into a peripheral i.v. Practice was then changed to preservative-free normal saline, and data collection continued for 117 neonates. MAIN OUTCOME VARIABLE: I.v. catheter longevity. RESULTS: There was no significant statistical difference in i.v. catheter longevity between i.v. locks flushed with 10 units/ml heparin and those flushed with normal saline. Patient weight accounted for a significant proportion of the variance in i.v. catheter life.

Guideline for i.v. infiltrations in pediatric patients.

A large Midwestern tertiary care center used a multidisciplinary approach to develop an intravenous infiltration/extravasation guideline for pediatric patients, ages 0-18 years old, using the Iowa Model for research utilization. This infiltration clinical practice guideline included a site appearance staging tool, decision algorithm, research-based antidotes, and standard of care. The goal of the guideline was to prevent or minimize adverse occurrences for pediatric patients at risk for intravenous infiltrations. Quality assessment and improvement tracking suggested that there was an increased consistency in use of practice guideline interventions for and reporting of the infiltration event, a reduction in adverse patient outcomes and potential cost savings.

Cognitive behavioral interventions for children during painful procedures: research challenges and program development.

The purpose of this report is to describe a pilot program designed to introduce the use of cognitive behavioral interventions for painful pediatric procedures at a university hospital, and to discuss the challenges that occurred during this process. Participants in the program included ten parents and their children who were newly diagnosed with leukemia, and staff who provided treatment for these children. Measures included direct videotaped observations of the children, perceptions of pain and anxiety completed by children, parents, and staff, and parent and staff ratings of satisfaction with the program. Results indicated strong acceptance of the interventions. This report discusses the challenges encountered, implications of the findings, and plans for future program development.

Diarrhea associated with nasogastric feedings.

PURPOSE/OBJECTIVES: To determine the difference in the incidence of diarrhea among subjects given one of three formulas with varying fiber concentrations administered by nasogastric (NG) tube, variables affecting incidence of diarrhea, discomforts other than diarrhea associated with NG tube feedings, and effects of changing from continuous to interval feedings on incidence of diarrhea and discomforts. DESIGN: Prospective, double-blind, randomized study. SETTING: Midwestern tertiary care center otolaryngology nursing unit. SAMPLE: Eighty randomized subjects who were 18 years or older, English-speaking, and undergoing head and neck cancer surgery that required an NG tube postoperatively and who had no gastrointestinal (GI) illness within two weeks prior to surgery. METHODS: Subjects received continuous administration of formula containing no fiber, 7 gms/L of fiber, or 14 gms/L of fiber until they reached the caloric intake goal and then were advanced to interval feedings. Patients' medical records provided past medical history and information on medication administration. A bedside flow sheet was used for documenting incidence of diarrhea and other GI discomforts. MAIN RESEARCH VARIABLES: Amount of fiber in the formula administered, patient's genders and prior food aversions, and antibiotics' effect on diarrhea and other GI discomforts. FINDINGS: Multiple logistic regression showed significant odds ratios (ORs) for developing diarrhea in female subjects (OR = 7.96), subjects who had prior food aversions (OR = 2.67), and subjects receiving broad spectrum antibiotics (OR = 3.22). Diarrhea was four times more likely to occur in males who received fiber-free formula. Of all subjects, 70% experienced GI discomforts with continuous feedings, and 50% experienced discomforts when advanced to interval feedings. CONCLUSIONS: Fiber formulas reduced the incidence of diarrhea in male subjects but not in female subjects. Antibiotics' effect on diarrhea paralleled the findings of other studies. IMPLICATIONS FOR NURSING PRACTICE: Use formulas with fiber for males. Liquid stools do not require interruption of tube feeding; GI discomforts warrant interruption. Interval feeding schedules require monitoring similar to continuous feeding schedules.

Development of an enteral feeding protocol.

Diarrhea following tube feedings in postoperative head and neck oncology patients is a significant problem. The existing tube feeding protocol was evaluated and clarified. A study was also undertaken to reduce the incidence of diarrhea in this patient population.

Evaluation of saline for i.v. locks in children.

A practice change to saline for peripheral IV maintenance was evaluated in a large teaching hospital in the Midwest. Subjects (N = 126) were children over 28 days of age, with peripherally placed IVs. Group I (n = 68) were children randomly selected to receive saline flush in an experimental study. Group II (n = 58) consisted of children receiving the saline flush after the change in practice was made. There was no significant difference between groups for either of two measures of IV duration. The mean duration of the IV from first flush was 35.38 hours for Group I and 44.09 hours for Group II; the time from insertion to discontinuation was 60.86 and 60.03 hours respectively. Patient age, site location, number of flushes, number of irritating medications, and site complications did not differ significantly between groups. The results of this clinical evaluation support previous findings that saline is efficacious for maintaining the patency of peripheral IVs in children over 28 days of age.

Heparin vs. saline for peripheral i.v. locks in children.

PURPOSE: To determine the efficacy of saline versus heparin flush solution to maintain peripheral i.v. locks in a pediatric population. METHOD: A prospective, randomized, double-blind design was used. A sample of 124 peripheral i.vs. were flushed with either saline or heparin in saline. Subjects were infants over 28 days of age and children. FINDINGS: The heparin and saline groups were comparable for total hours duration of the i.v. and for incidence of complications. CONCLUSIONS: Saline is efficacious in maintaining patency of peripheral i.v. locks in children over 28 days of age.

From hopeful to hopeless ... when do we write "do not resuscitate"?

The issue of do not resuscitate (DNR) decisions has been the subject of much discussion in the medical literature. To try to understand the factors that may be determinants of the timing of DNR decisions, we reviewed the charts of 70 consecutive burned patients who died between 1986 and 1988. When a DNR decision was written, it was within 48 hours of the patient's death (74% of patients). No statistical difference was found in the sex distribution or in the percentage of body surface area burned in the DNR group and in the resuscitation group. Physicians, nurses, social workers, the hospital attorney, the district attorney, and the coroner of our county were interviewed. The uncertainty of legal guidelines and practical considerations of family expectations preclude a uniform approach to this problem.

Munchausen Syndrome by Proxy: a nursing overview.

Munchausen Syndrome by Proxy is a common but often undetected form of child abuse in which a parent fabricates or falsifies an illness in the child and then presents the child for medical treatment, disclaiming knowledge as to the etiology of the illness. Nurses are instrumental in the early identification and detection of Munchausen Syndrome by Proxy. A case study emphasizes the role of nurses as part of the multidisciplinary approach. Use of the nursing process demonstrates comprehensive care in management.