High frequency acoustic parameters of human and bovine articular cartilage following experimentally-induced matrix degradation.

Matrix degradation and proteoglycan loss in articular cartilag eare features of early osteoarthritis. To determine the effect of matrix degradation and proteoglycan loss on ultrasound propagation in cartilage, we used papain and interleukin-1alpha to degrade the matrix proteoglycans of human and bovine cartilage samples, respectively. There is also minor collagen alteration associated with these chemical degradation methods. We compared the speed of sound and frequency dependent attenuation (20-40 MHz) of control and experimental paired samples. We found that a loss of matrix proteoglycans and collagen disruption resulted in a 20-30% increase in the frequency dependent attenuation and a 2% decrease in the speed of sound in both human and bovine cartilage. We conclude that the frequency dependent attenuation and speed of sound in articular cartilage are sensitive to experimental modification of the matrix proteoglycans and collagen. These findings suggest that ultrasound can potentially be used to detect morphologic changes in articular cartilage associated with the progression of osteoarthritis.

Caring in action: the key to nursing service excellence.

One of the key factors for organizational success is service excellence. Nursing service has been proved to be a pivotal factor in the overall patient satisfaction rating on hospital surveys. The article describes a service improvement implemented by one nursing service that improved patient satisfaction survey results. Standards developed were expanded to all departments to affect the entire organization.

Utilizing quality assurance as a tool for reducing the risk of nosocomial ventilator-associated pneumonia.

A multidisciplinary group was formed to develop strategies to reduce ventilator-associated lower respiratory tract infections (LRI) in an intensive care unit (ICU) of a 540-bed acute care teaching medical center. The group process was facilitated by the Infection Director and the quality management specialist. The group was made of medical, nursing, and respiratory therapy staff. Quality improvement techniques were used to define the process of care for ventilated patients in the ICU. "State of the art" care was defined after a literature review and brainstorming sessions. Current practice and new concepts were then forged into a realistic protocol for the ICU. The resulting protocol was introduced into the ICU in May 1992. The information was communicated to Respiratory Therapy and ICU staff in writing and at department meetings. After a 4-month introductory period and learning curve process, a decrease in the endemic rate of ventilator-associated LRI was reduced in the fourth quarter of 1992. The mean 1993 LRI rate was 21 LRI/1000 ventilator days versus 26 LRI/1000 ventilator days in 1992 before protocol implementation. This equates to 18 LRI prevented in 1993. This represents a savings of $126,000. There was a significant decrease in the process variation of the monthly mean LRI/1000 ventilator days in 1993 from 1992. To date, there continues to be improvement with a mean of 16 LRI/1000 ventilator days reported in 1994. The ICU staff developed a multidisciplinary process evaluation and monitored staff implementation of the protocol over time. The results of the evaluation were used as feedback to measure protocol implementation. This was found to improve compliance with the protocol. Both the process (care of ventilated patients) and the outcome (number of LRI) have been improved through use of continuous quality improvement concepts and transdisciplinary interventions.

Developing a proactive approach to medication error prevention.

Medication administration and the prevention of medication errors have been identified by quality management professionals and consumers alike as an area of healthcare that needs quality improvement. A proactive multi-disciplinary approach taken by nursing and pharmacy at the author's acute care teaching hospital has resulted in a significant improvement in the medication administration process and in reduced medication errors. Improved quality data management resulted in more effective action planning. The reporting format of medication errors was changed based on trends, and severity evaluation was implemented. System problems were more easily identified due to increased information about the medication errors. As a result, staff education and training could be more specific, and thus, more meaningful. Additionally, jointly developed quality management studies provided the foundation for effective improvement strategies and efficient system changes.

Neoplastic cardiac tamponade.

Once thought to be rare, neoplastic cardiac tamponade is beginning to be recognized more frequently, and is occasionally the presenting symptom of neoplastic disease. This article provides the critical care nurse with the knowledge necessary for care of the patient with neoplastic cardiac tamponade.