Outcomes following physical restraint reduction programs in two acute care hospitals.

BACKGROUND: Physical restraint rates can be reduced safely in long term care settings, but the strategies used to prevent wandering, falls, and patient aggression have not been tested for their effectiveness in preventing therapy disruption. A restraint reduction program (RRP) consisting of four core components (administrative, educational, consultative, and feedback) was implemented in 1998-1999 in 14 units at two acute care hospitals in geographically distant cities. METHODS: The RRP was targeted at units with prevalence rates of > or = 4% for non-intensive care units (non-ICUs) and > or = 25% for ICUs, as well as two additional units. The RRP was implemented by an interdisciplinary team consisting of geriatricians and nurse specialists. RESULTS: Of the 16,605 admissions to the RRP units, 2,772 cases received RRP consultations. Only six units (four of seven general units and two of six ICUs) demonstrated a relative reduction of > or = 20% in the physical restraint use rate. No increase in secondary outcomes of patient falls and therapy disruptions (patient-initiated discontinuation or dislodgment of therapeutic devices) occurred, injury rates were low, and no deaths occurred as a direct result of either a fall or therapy disruption event. DISCUSSION: Given the minimal success in the ICU settings, further studies are needed to determine effective nonrestraint strategies for critical care patients. ICU clinicians need to be persuaded of the favorable risk-to-benefit ratio of alternatives to physical restraint before they will change their practice patterns. SUMMARY: Efforts to identify more effective interventions that match patient needs and to identify non-clinician factors that affect physical restraint use are needed.

Elderly patients' reports of physical restraint experiences in intensive care units.

BACKGROUND: Use of physical restraints has undesirable sequelae. As they weigh the risks and benefits of protocols for reducing the use of restraints, staff members in intensive care units, where restraints are most used in hospitals, need to know how well elderly patients remember being restrained and how patients perceive the use of restraints. OBJECTIVES: To estimate the proportion of patients who remember being restrained, describe the experience from the patients' perspectives, and describe any distress caused by use of restraints within the overall experience of being in the intensive care unit. METHODS: Transcripts of semistructured, audiotaped interviews of patients who had been in the medical or surgical intensive care unit in any of 3 eastern and midwestern medical centers were analyzed by question and for overall themes. RESULTS: Six patients (40%) remembered some aspect of being restrained but did not report great distress. Patients accepted restraints as needed because of the lack of alternatives. Patients reported remembering that they should not perform certain behaviors but being unable to stop themselves. Patients cited hallucinations and intubation as major stressors in the intensive care unit. Patients' continuing health problems after discharge from the intensive care unit severely limited recruitment of subjects. CONCLUSIONS: Patients do not remember great distress specifically related to the use of restraints, but the overall situation leading to use of restraints is disturbing if remembered. The discovery of methods to reduce the distress of intubation and hallucinations could decrease use of restraints.

Use of a faculty investment model to attain the goals of a college of nursing.

Driven by demands for fiscal prudence, new services, and an orderly transition as aging faculty approach retirement, a new model for administrative planning and decision making was tested. In its first year of using an investment model, a private, 600+ student, College of Nursing was able to achieve a labor savings of 10 percent, an enhancement of revenue of 3 percent, and a human capital pool equal to 12 percent of total full-time faculty equivalents. The model, which includes the integration of strategic planning, benchmarking, continuous quality improvement, and management by objectives, was accomplished by taking three investment steps. The steps included goal determination, market understanding, and resource allocation. Investment activity distribution and work determination frameworks were developed as a result of the commitment to the investment process. Suggestions for the future include the need to continue to reorient administrative and faculty thinking as definitions of the educational enterprise evolve.

The restraint match-up. Three lessons show how nurse leaders can influence the use of physical restraints.

A study of three hospitals reveals common areas where nurse managers can change the use of physical restraints.

Retirement, the nursing workforce, and the year 2005.

This analysis of workforce projections confirms that early employment withdrawal by registered nurse baby boomers could have a profound effect on US health care. The available policy mechanisms to encourage or discourage any early withdrawal require several years to implement, which makes timely decisions imperative.

Beyond interviewing skills: twelve steps for training interviewers.

The measurement of many outcomes relies on patients and their families for information that can best be collected through interviews. The authors describe 12 practical suggestions that help ensure achievement of subject enrollment and interview goals.

Levels of data: the whys and hows of selection and analysis.

There are many challenges in selecting the level of a variable for data collection and analysis. Meeting these challenges is labor intensive and requires considerable skill; however, if a performance improvement project is to produce sound results, shortcuts cannot be taken. Studies that purport to show the impact of important variables on care influence the allocation of resources. The choice of a working unit level of analysis may be highly useful in meeting project goals and statistical requirements, but familiarity with multilevel techniques remains essential. If all or some of the variables must be aggregated, information about individual response rate, the extent and treatment of missing data, and tests of the collinearity of the aggregate data need to be made before proceeding with the analysis.

Irreversible inhibition of epidermal growth factor receptor tyrosine kinase with in vivo activity by N-[4-[(3-bromophenyl)amino]-6-quinazolinyl]-2-butynamide (CL-387,785).

It has been shown previously that 4-anilino quinazolines compete with the ability of ATP to bind the epidermal growth factor receptor (EGF-R), inhibit EGF-stimulated autophosphorylation of tyrosine residues in EGF-R, and block EGF-mediated growth. Since millimolar concentrations of ATP in cells could reduce the efficacy of 4-anilino quinazolines in cells and the activity of these compounds would not be sustained once they were removed from the body, we reasoned that irreversible inhibitors of EGF-R might improve the activity of this series of compounds in animals. Molecular modeling of the EGF-R kinase domain was used to design irreversible inhibitors. We herein describe one such inhibitor: N-[4-[(3-bromophenyl)amino]-6-quinazolinyl]2-butynamide, known as CL-387,785. This compound covalently bound to EGF-R. It also specifically inhibited kinase activity of the protein (IC50 = 370+/-120 pM), blocked EGF-stimulated autophosphorylation of the receptor in cells (ic50 approximately 5 nM), inhibited cell proliferation (IC50 = 31-125 nM) primarily in a cytostatic manner in cell lines that overexpress EGF-R or c-erbB-2, and profoundly blocked the growth of a tumor that overexpresses EGF-R in nude mice (when given orally at 80 mg/kg/day for 10 days, daily). We conclude that CL-387,785 is useful for studying the interaction of small molecules with EGF-R and may have clinical utility.

Comparison between reports of care obtained by postdischarge telephone interview and predischarge personal interview.

The question of when to survey patients is the subject of ongoing debate because of the rising interest in monitoring quality from the consumer's perspective. This study of 772 randomly assigned patients from 17 hospitals compared results from predischarge in-person interviews (HI) and postdischarge telephone interviews (PHTI) for differences in participation rates, respondents' characteristics, and reports of quality most affected by nursing. The methods were equally costly. The results suggest that hospital interviews may enhance response rates of some vulnerable patient groups without jeopardizing the results.

Help the health care team release its hold on restraint.

As part of a three-site cooperative physical restraint reduction program in acute-care hospitals, a multidisciplinary team created a survey instrument to measure staff's knowledge, unit beliefs about practice patterns, ethical concerns, and more.

Improving the ability to detect the impact of labor on patient outcomes.

A key part of resource allocation decisions is determining the impact of staffing on clinical outcomes. A national study involving eight hospitals and 77 units lends support for a previously identified labor assignment phenomena that may contribute to an underestimation of the impact of nursing labor on outcomes if only traditional labor measurement methods are used. The authors suggest actions for nurse administrators and researchers who must address frequent queries as to the adequacy of nursing staffing.

Prevalence and patterns of physical restraint use in the acute care setting.

Nurse executives usually have the principal responsibility to respond to the national movement to reduce physical restraint use in hospitals. The results of this three-site, interdisciplinary, prospective incidence study (based on more than 49,000 observations collected on 18 randomly selected days) reveal new patterns in the rationale and types of restraints used. The authors discuss how the results can be used in measuring success and allocating resources for restraint reduction programs.

Education in administration. Trends in MSN/MBA and MSN in nursing administration.

Avenues for the preparation of nurses who wish to pursue administrative careers continue to be debated. The author reports changes in the numbers and enrollments of master of science in nursing/master of business administration (MSN/MBA) programs as well as trends in MSN in nursing administration programs since 1993. Respondents to a survey of all U.S. nursing graduate programs indicated that both types of programs have undergone substantial changes on a variety of measures. The author considers these results in suggestions for building new approaches to administrative preparation.

Use of administrative personnel in hospitals: a three nation comparison.

Differences in the costs of health care systems among industrialized countries has been the focus of several studies. Labor costs, specifically the amount of resources used for administration, are considered to contribute to differences in overall health care costs. To determine differences in the use of labor resources, especially administrative and managerial, among American, Austrian and German hospitals, we use a convenience sample of one Austrian, one German and two United States (US) tertiary care centers. In our analysis we used payroll data of the four hospitals. First, we categorized job titles and created job categories. Subsequently, we calculated full time equivalents (FTEs) per job category and compared them across countries. Adjustments were made for differences in health systems. The main outcome measures were FTEs per patient day and per discharge in each job category. In the US hospitals > 19% of FTEs were in administrative categories as compared with < 8% in the European hospitals. For administrative managers, US hospitals used > 11 times the labor per patient day of the European institutions. Among administrative areas, the largest absolute FTE difference was in financial operations. US hospitals used > 5 FTEs of personnel per 10,000 patient days versus < 1.0 FTE in the European hospitals. Given the kinds of administrative work done in US hospitals compared to Austria and Germany, differences in the organization and financing of these countries' health care systems may account for an important part of the higher number of US personnel.

Relationship of nonstaging pathological risk factors to lymph node metastasis and recurrence in clinical stage I endometrial carcinoma.

OBJECTIVE: To determine if DNA ploidy, hormone receptors, vascular space invasion (VSI), perivascular lymphocytes (PVL), and the oncogenes HER-2/neu, p53, and bcl-2 are independent prognostic indicators for lymph node metastasis and cancer recurrence in clinical stage I endometrial carcinoma. METHODS: Among 349 patients with clinical stage I endometrial cancer 31 patients either had lymph node metastases when surgically staged or developed recurrent cancer. Using a case-control matched-pair technique, controls were selected for each of 24 cases by matching for age, histological grade, depth of myometrial invasion, performance of node dissection, and use of adjuvant radiation therapy. In a blinded fashion a pathologist reviewed all histopathology, and all molecular tests were performed on paraffin-embedded tissue samples. Statistical analysis was performed by chi2 and McNemar's tests. RESULTS: VSI was the only histopathological factor significantly related to positive lymph nodes and cancer recurrence (P = 0.01), independent of grade and myometrial invasion. Aneuploidy, oncogene expression (p53, HER-2/neu, bcl-2), and hormone receptors were not significantly related to lymph node metastasis and cancer recurrence. CONCLUSIONS: The presence of vascular space invasion is a pathological factor independently associated with a risk of nodal metastasis and cancer recurrence in clinical stage I endometrial cancer. DNA ploidy, oncogene expression, and hormone receptor status do not have more predictive value than standard staging pathological criteria.

Key issues in building a continuum of care.

The recognition of the effects of a failure to attain continuity of care is driving many of the changes in U.S. health care. This article explores the relationship of continuity of care and the broader concept of a continuum of care. Actions that advanced practice nurses, educators, and organizations can take to influence its developmental are described within the context of three issues: (1) recognition of continuity of care myths, (2) the use of financial mechanisms to promote the construction of a continuum of care, and (3) the development of continuum of care building skills of advanced practice nurses.

Role of endogenous ANG II and AT1 receptors in regulating arterial baroreflex responses in newborn lambs.

The present study was designed to test the hypothesis that endogenous angiotensin II (ANG II) influences baroreflex control of heart rate (HR) and renal sympathetic nerve activity (RSNA) early in life and to determine whether these actions are mediated by angiotensin AT1 or AT2 receptors. To test this hypothesis, we studied the effects of systemic and central administration of losartan, a selective AT1 receptor antagonist, and PD-123319, a selective AT2 antagonist, on baroreflex-mediated control of HR and RSNA in conscious newborn lambs. Systemic administration of losartan decreased resting mean arterial blood pressure (MABP) from 70 +/- 3 to 58 +/- 4 mmHg (P < 0.05) without producing reflex increases in HR or RSNA. The baroreflex response curves were shifted to the left as indicated by a decrease in the arterial pressure at the midpoint of the curve for HR (83 +/- 3 to 75 +/- 4 mmHg) and RSNA (74 +/- 2 to 69 +/- 3 mmHg; P < 0.05 for both). Losartan also reset HR and RSNA baroreflex curves when changes in baseline blood pressure were prevented by simultaneous infusion of phenylephrine. In contrast, a sustained decrease in arterial pressure of 10-12 mmHg with nitroprusside failed to shift the baroreflex function curves. PD-123319 had no effect on baseline HR, MABP, RSNA, or baroreflex responses. Lateral ventricle administration of losartan but not PD-123319 also produced a decrease in arterial pressure (81 +/- 4 to 73 +/- 3 mmHg, P < 0.05) and reset the baroreflex for HR and RSNA toward lower pressure. These results demonstrate that, early in life, endogenous ANG II exerts a tonic effect on baroreflex control of HR and RSNA to shift the curves toward higher pressure levels. The alterations in arterial baroreflex function appear independent of direct ANG II effects on arterial pressure and are mediated by AT1 receptors.

What influences patients' reports of three aspects of hospital services?

OBJECTIVES: Market forces make it essential to know what policies and actions influence patients' reports of hospital services. No studies have examined the role of patient characteristics, labor quality and staff characteristics, nonlabor resources, managerial practices, and employee attitudes within a single investigation. METHODS: The authors collected, simultaneously, data about labor, management and service processes, nonlabor resources, and employee attitudes on 117 nonintensive medical-surgical inpatient units in 17 hospitals selected from a pool of 69 institutions within a metropolitan area by a stratified random sample. Of the 2,595 patients who agreed to participate, 2,051 (79%) completed telephone interviews regarding their experiences with physical care, education, and pain management services within 26 days of hospital discharge. RESULTS: A significant amount of variation in patients' service reports was explained (adjusted R2 = 0.41 physical care, 0.35 pain management, 0.44 education). Although the predictors varied for each service report, patient characteristics, especially those related to personal resources, had a large explanatory role. A labor assignment pattern that could explain why earlier studies found labor quality and staff characteristics to have only a weak role in the prediction of patients' service reports was noted. CONCLUSIONS: The results related to patient characteristics may indicate opportunities to improve care by confronting service design strategies that erroneously rely on a homogeneous patient population. Measurement challenges identified by this study must be addressed to determine the role of labor quantity and staff characteristics.

Initiatives to build a competitive healthcare system: integrating service redesign and clinical pathways.

In this article, the authors describe how two separate initiatives (the redesign of hospital services and the development and implementation of clinical pathways) were integrated at an academic medical center. The lessons learned in integrating projects that were not conceived at the same time and in developing multidisciplinary teams to produce new case management tools may be used by clinicians and managers elsewhere. The service redesign project developed a role for senior, experienced nurses with clinical expertise and patient management skills to manage the care of groups of similar patients, focusing on patient outcomes. The clinical pathway project developed diagnostic related groups-based clinical pathways. The steps involved in clinical pathway development-stakeholder cooperation building, initiation of data collection tools, data analysis, implementation of the role of the expert nurse in "championing" the pathway, and evaluation of the effects of pathways-are discussed.