Enhancing outcomes: guidelines, standards, and protocols.

Guidelines, protocols, and standards have gained attention as clinical tools designed to enhance clinical decision-making and practice. Yet, evidence has emerged that clinicians are having difficulty integrating new knowledge presented by these tools into practice. This article explores the benefits and barriers to using guidelines and protocols, probes the issues of producing these tools, and examines processes that are critical to constructing valid tools. The key functions important in successful development and implementation of guidelines and protocols are presented, as well as the direction these clinical adjuncts will take in the future.

Current practices regarding visitation policies in critical care units.

BACKGROUND: Previous research has emphasized the importance of visitation in critical care units and its beneficial effects on patients and their families. However, nurses' attitudes and beliefs about visitation did not correlate with those of patients and their families, nor did actual visitation practices correlate with written policy. OBJECTIVE: To investigate nurses' perceptions about open vs restricted visiting hours and the effects on the patient, the patient's family, and the nurse. METHODS: Quantitative and qualitative data were collected from 201 nurses who completed a survey instrument about nurses' perceptions of visitation at five metropolitan hospitals in a midwestern city. RESULTS: Seventy percent of official policies for visitation were restrictive. In practice, 78% of nurses were nonrestrictive in their visitation practices. Variables that affected practices regarding visiting hours were the patient's need for rest, the nurse's workload, and the beneficial effects of visitation on patients. Requests from patients and their families were ranked least important. Significant differences in practices were found regarding restriction of visiting by immediate family members and of the number of visitors. Restricted hours were perceived to decrease noise (83%) and promote patients' rest (85%). Open visitation practices were perceived to beneficially affect the patient (67%) and the patient's family (88%) and to decrease anxiety (64%). Perceptions of ideal visiting hours included restrictions on the number of visitors (75%), hours (57%), visits by children (55%), and duration of visits (54%), but no restriction on visitation by immediate family members (60%). Qualitative data revealed recurrent themes in visitation practices, policies and exceptions, control of visitation by patients, and nurses' wishes. CONCLUSION: Data indicate that most nurses do not restrict visitation, regardless of whether restrictive policies are in place. Most nurses base their visitation decisions on the needs of the patient and the nurse. Needs of the family were ranked as less important in decision making about family visitation.

Acute pancreatitis.

The patient with acute pancreatitis requires constant assessments and interventions to minimize pancreatic inflammation and promote early detection and treatment of systemic complications. The onset of acute pancreatitis is most commonly initiated by biliary or alcohol disease, although many other causes have identified. The course of the disease may range from mild to fulminant based on the degree of pancreatic necrosis. Significant clinical symptoms include abdominal pain, nausea, and vomiting. The patient may present with signs of hypovolemic shock, with associated sequestration of fluid in the peritoneum as a result of inflammatory and mediated responses. Laboratory evidence of the disease includes increased levels of amylase and lipase, although a definitive diagnosis cannot be made without radiographic tests. Multisystem failure can occur in necrotizing acute pancreatitis as a result of mediators that are activated by the proteolytic enzymes, normally produced by the pancreas, and released into the peritoneum by injured cells. Collaborative management of the patient includes therapies directed at correcting initiating events, hemodynamic stabilization, and supportive measures to rest the pancreas and resolve presenting clinical symptoms. The management of multisystem organ failure that can result from necrotizing pancreatitis is a multidisciplinary challenge.

Group facilitation: building that winning team.

Team building does not occur by chance; it involves using techniques to make it easier for members to contribute their expertise while working with others to achieve quality results. Evaluation of team effectiveness involves assessing both the processes (team interactions and work processes) and accomplishment of goals (out-comes; see box). Productivity and quality that could not be accomplished by individual efforts may be enhanced by effectively working teams.

Linking critical care family research to quality assurance.

The Joint Commission on Accreditation of Health Care Organizations standards require the inclusion of all major clinical functions performed by nurses in the nursing quality assurance (QA) program. To achieve this goal, nurses must first define the scope of care, which includes articulating the specific activities performed in the critical care unit, who provides the care, where and when nursing care is provided, and to whom nursing care is provided. Interventions directed toward families are recognized as falling within the scope of nursing practice. This article addresses how family research was used to develop a QA tool to evaluate family satisfaction with nursing interventions to meet their identified needs in an intensive care unit setting.

Spinal cord injury: a comparison of preinjury and postinjury marriages.

A study of the preinjury and postinjury marriages of 55 spinal cord injured persons and their partners revealed several differences between the relationships. Although all patients had comparable levels of spinal cord injury, the disabled persons in preinjury marriages were judged to have less motivation for independence; a larger proportion of them received daily personal care assistance from their spouses. Furthermore, those in postinjury marriages were more likely to be employed and were judged to be better adjusted psychologically. Psychologists' assessment of marriages based on interviews with the spinal cord injured subjects and their spouses revealed that the postinjury marriages were happier than the preinjury marriages. Possible explanations for these findings are discussed, which include age and state of health, the impact of disability on the marital relationship and the personal assets of disabled persons who attract new partners.