Critical care of the child with increased intracranial pressure

The nursing care of children with increased intracranial pressure is extremely complex. For children with intracranial pressure monitoring devices in place or for those who are maintained on a barbiturate coma regimen, the nurse must have extensive knowledge regarding the proper operation of the complex equipment that is helping to maintain the child's life. However, no matter how sophisticated the monitoring equipment or no matter what new research protocol is being followed, the child's life is dependent upon the nurse providing care. If the nurse fails to interpret the clinical findings correctly and does not notify the physician promptly, the child may suffer permanent neurologic dysfunction. Furthermore, the nurse must be cognizant of nursing actions--routine activities such as changing the child's position--that could have a dramatic effect on the child's intracranial pressure. Given time, expert nursing care, a multidisciplinary rehabilitation team, and a supportive family, many children who have severely increased intracranial pressures survive the insult without sustaining severe neurologic dysfunction.     

Optimizing the electrocardiogram and pressure monitoring

Monitoring the electrocardiogram and directly measuring BP provide current and important data for intraoperative and ICU patient management. However, these physiologic measurements are not infallible; their accuracy is largely dependent on the careful set-up and use of the measuring instruments. This report integrates practical clinical and engineering information to provide a basis for optimizing ECG and pressure monitoring in the clinical setting.     

Characteristics of occasional and frequent emergency department users: do insurance coverage and access to care matter?

OBJECTIVE: The objective of this study was to explore how insurance coverage, access to care, and other individual characteristics are related to the large differences in emergency department (ED) use among the general population. MATERIALS AND METHODS: We used the 1997 and 1999 National Survey of America's Families, a nationally representative sample. People were classified into 3 ED use levels based on the number of visits over the 12 months before the survey: non-ED users (zero visits), occasional users (1 or 2 visits), or frequent users (3 or more visits). We used a multinomial logit model to estimate the effect of insurance status and other factors on levels of ED use, and to compute the odds ratios of being occasional and frequent users as opposed to nonusers among various subpopulations. RESULTS: People in fair/poor health are 3.64 times more likely than others to be frequent ED users as compared with nonusers. The uninsured and the privately insured adults have the same risk of being frequent users, but publicly insured adults are 2.08 times more likely to be frequent users. Adults who made 3 or more visits to doctors are 5.29 times more likely to be frequent ED users than those who made no such visits. CONCLUSION: The uninsured do not use more ED visits than the insured population as is sometimes argued. Instead, the publicly insured are overrepresented among ED users. Frequent ED users do not appear to use the ED as a substitute for their primary care but, in fact, are a less healthy population who need and use more care overall.     

Which cardiac surgical patients can benefit from placement of a pulmonary artery catheter?

The use of pulmonary artery catheters (PACs) during cardiac surgery varies considerably depending on local policy, ranging from use in 5-10% of the patient population to routine application. However, as in other clinical fields, recent years have witnessed a progressive decline in PAC use. One of the reasons for this is probably the increasing use of transoesophageal echocardiograpy, even though careful analysis of the information provided by PAC and transoesophageal echocardiograpy indicates that the two tools should be considered subsidiary rather than alternatives. The principal categories of cardiac patients who can benefit from PAC monitoring are those with present and those with possible haemodynamic instability. On this basis we can identify five groups: patients with impaired left ventricular systolic function; those with impaired right ventricular systolic function; those with left ventricular diastolic dysfunction; those with an acute ventricular septal defect; and those with a left ventricular assist device. This review highlights the specific role of PAC-derived haemodynamic data for each category.     

Severe hypertension in the emergency department patient

Severely elevated blood pressure is a common clinical problem en-countered in the Emergency Department. It is often difficult for physicians to differentiate between patients who need emergent blood pressure reduction, requiring the use of intravenous agents and in-tensive monitoring, and those for whom careful, slow reduction in BP is more appropriate. The optimal assessment and management of these patients is reviewed here, with an emphasis on clinical strategies that will most efficiently identify those at greatest risk.     

A review of screening tools for psychiatric comorbidity in headache patients

Psychiatric comorbidity, especially depression and anxiety, has been well documented in patients with primary headache disorders. The presence of psychiatric comorbidity in headache patients is associated with decreased quality-of-life, poorer prognosis, chronification of disease, poorer response to treatment, and increased medical costs. Despite the prevalence and impact, screening for psychiatric disorders in headache patients is not systematically performed, either clinically or in research studies, and there are no guidelines to suggest which patients should be screened or in what manner. We review a variety of screening methods and instruments, focusing primarily on self-report measures and those available in the public domain. Informal verbal screening may be sufficient in a primary care setting, but should include screening for both anxiety and depression. Explicit screening for anxiety is important, as anxiety may have a more significant impact on headache than does depression and may occur in the absence of clinical depression. Formal screening with instruments that can identify a variety of psychiatric disorders is appropriate for patients with daily headache syndromes, patients who are refractory to usual care, and patients referred for specialty evaluation. Limitations of screening instruments include the influence of transdiagnostic symptoms and the need for confirmatory diagnostic interview. The following instruments appear most suitable for use in headache patients: for depression, the Patient Health Questionnaire Depression Module, the Beck Depression Inventory-II, or the Beck Depression Inventory-Primary Care; for anxiety, the Beck Anxiety Inventory and the Generalized Anxiety Disorder 7-item Scale; and for multidimensional psychiatric screening, the Patient Health Questionnaire or Primary Care Evaluation of Mental Disorders.     

A Review of Screening Tools for Psychiatric Comorbidity in Headache Patients

Psychiatric comorbidity, especially depression and anxiety, has been well documented in patients with primary headache disorders. The presence of psychiatric comorbidity in headache patients is associated with decreased quality-of-life, poorer prognosis, chronification of disease, poorer response to treatment, and increased medical costs. Despite the prevalence and impact, screening for psychiatric disorders in headache patients is not systematically performed, either clinically or in research studies, and there are no guidelines to suggest which patients should be screened or in what manner. We review a variety of screening methods and instruments, focusing primarily on self-report measures and those available in the public domain. Informal verbal screening may be sufficient in a primary care setting, but should include screening for both anxiety and depression. Explicit screening for anxiety is important, as anxiety may have a more significant impact on headache than does depression and may occur in the absence of clinical depression. Formal screening with instruments that can identify a variety of psychiatric disorders is appropriate for patients with daily headache syndromes, patients who are refractory to usual care, and patients referred for specialty evaluation. Limitations of screening instruments include the influence of transdiagnostic symptoms and the need for confirmatory diagnostic interview. The following instruments appear most suitable for use in headache patients: for depression, the Patient Health Questionnaire Depression Module, the Beck Depression Inventory-II, or the Beck Depression Inventory-Primary Care; for anxiety, the Beck Anxiety Inventory and the Generalized Anxiety Disorder 7-item Scale; and for multidimensional psychiatric screening, the Patient Health Questionnaire or Primary Care Evaluation of Mental Disorders.     

Instruments for monitoring intensive care unit sedation

Although many promising objective methods (measuring systems) are available, there are no truly validated instruments for monitoring intensive care unit (ICU) sedation. Auditory evoked potentials can be used only for research in patients with a deep level of sedation. Other measuring systems require further development and validation to be useful in the ICU. Continuing research will provide an objective system to improve the monitoring and controlling of this essential treatment for ICU patients. Subjective methods (scoring systems) that are based on clinical observation have proven their usefulness in guiding sedative therapy. The Glasgow Coma Score modified by Cook and Palma (GCSC) achieves good face validity and reliability, which assures its clinical utility for routine practice and research. Other scales, in particular the Ramsay Scale, can be recommended preferably for clinical use. An accurate use of available instruments can improve the sedative treatment that we deliver to our patients.     

再次换瓣手术的配合体会

笔报道40例再次换瓣手术的配合体会，强调做好术前准备，包括手术特殊器械、抢救药品、急救仪器等。术中配合过程中洗手护士熟悉手术步骤，了解特殊器械使用时机及方法；巡回护士严密观察心电图及血压，做好抢救准备，以确保手术顺利进行。     

Blunt trauma in the obstetric patient: monitoring practices in the ED

This study was undertaken to determine the usually used approach to fetal monitoring in the emergency department (ED) of the less severely injured obstetric patient who has sustained blunt trauma. A written survey was sent to clinical directors of teaching programs in emergency medicine (EM) with inquiries on the usual way of monitoring, what studies were performed, and the usual disposition of the less-injured obstetric patient. From the 112 teaching programs surveyed in early 1996, there were 87 responses (78%). Seventy-eight percent of programs generally have fetal monitoring performed for 2 to 4 hours in obstetric trauma patients when the trauma is more than minor extremity injury. In 68%, fetal monitoring was not performed in the ED from the time of the initial assessment of fetal heart tones until the mother went to an obstetric area even though the average estimated time to radiographically clear a cervical spine was 36 minutes. In 92% of programs residents are taught cardiotocographic changes indicative of fetal distress but only 15% have such monitoring equipment in their department. However, 51% do have sonographic equipment in their department. Given a patient with a viable fetus who has no abdominal pain, 46% routinely use fetal monitoring if the mechanism is a simple fall whereas 92% use monitoring only if the mechanism is a rollover motor vehicle collision or a strike to the abdomen. It is generally recognized that fetal distress may occur subtly without overt clinical signs and that obstetric area monitoring for a period of several hours should take place. However, most teaching programs do not institute continuous fetal monitoring during the first 30 to 60 minutes that the mother is undergoing her work-up even though residents are taught such monitoring.     

Should we monitor alveolar and inspiratory concentrations of anesthetic and respiratory gases?

One essayist suggests that continuous monitoring of alveolar and inspiratory concentrations of anesthetic and respiratory gases has little or no positive effect on patient outcome and may even be detrimental to patients. Such monitoring, he says, tends to remove anesthesiologists from personal contact with their patients. He recommends careful monitoring of fresh gas concentrations leaving the anesthetic machine, careful monitoring of inspired gas in a circle absorption breathing system, and improved training of anesthesiologists to prevent human error. Another essayist suggests that continuous monitoring of alveolar and inspiratory concentrations of anesthetic and respiratory gases is cost-effective and relatively simple. He says that such monitoring, without being a source of legal problems for its users, improves the quality of patient care.     

Demand management: another marketing tool or a way to quality care?

Demand management tools are population-based strategies used to control costs and improve utilization of services by assisting health consumers in maintaining their health and seeking appropriate health care. These tools are increasingly used by health care delivery systems and, in the US, by fiscal intermediaries, such as insurance companies. If these tools are not properly applied, there is a clear possibility that their use may lead a reduction of health care services with no improvement in clinical, humanistic, or economic outcomes. Demand management effectiveness has not been rigorously examined by the medical industry or academia. Before adopting or purchasing demand management technologies, health care systems should examine them carefully to determine how the tools were developed and who they were intended to serve. Once implemented, careful tracking of population outcomes is as necessary with these technologies as with any other technologies that can affect health care.     

Pressure area management: a static-led approach

An increase in expenditure and inappropriate use of pressure-relieving equipment, along with high-prevalence figures, initiated the evaluation of current practice of pressure damage prevention in an acute general hospital. This evaluation started with the organization of a project group, who (after a baseline audit) identified and procured the resources required to introduce and manage an effective pressure damage prevention programme. The investment in high-quality static mattresses for all patients including those who are at high risk of developing pressure damage was based on available clinical evidence. This investment meant a reduction in the amount of dynamic systems needed as many of those patients are at high risk of pressure damage, and are now successfully managed on a static system. The development of a local policy including documentation facilitated regular reassessment of risk level based on a risk assessment tool and clinical rationale. This static-led approach has reduced not only costs but also improved the appropriate allocation of pressure-relieving/reducing equipment. The approach has also simplified the choice of equipment for staff who were previously expected to match patients' needs with varying levels of dynamic mattress efficiency. This article highlights the action taken from the initial identification of a specific need through to the effective implementation, management and monitoring of this innovative practice.     

Monitoring outcomes in routine practice: defining appropriate measurement criteria

With the development of an internal market for health care, 'purchasing for outcomes' has become an important if somewhat rhetorical catchphrase. While there is emerging understanding about how it can be pursued, doubts are being expressed over an outcomes rather than a process emphasis. This debate has been confused by a failure to differentiate the role and importance of monitoring outcomes at an individual patient care level from those at an aggregate population/purchaser level.
The clinical need to collect outcomes data on individual patient care within routine care settings places additional requirements on measurement development and selection. Traditional measurement criteria, stressing reliability, validity and responsiveness to change, must be supplemented by criteria of feasibility of use, clinical utility and acceptability. One option is to select domains or items of interest from longer instruments initially designed for research, carefully selected in relation to the purposes of measurement. Further measurement criteria must be addressed which stress the relevance of the proposed instrument to the condition and to the participants in the clinical interaction: in particular, patient-centredness and sensitivity to the setting.
Monitoring the outcomes of individual patient care within routine clinical practice poses considerable challenges to researchers who are developing instruments and to clinicians who collect and use the data. A shift in emphasis is required towards more context-specific tests, addressing relevance to lay perceptions, to clinical use and to the condition and setting under review. The content validity, the responsiveness to patient-relevant and clinically relevant change and, of course, reliability must have greater primacy. In this way, outcome data which measure the quality of clinical practice and which provide appropriate criteria for research into effectiveness can be generated.     

Sociodemographic factors and the use of outpatient mental health services

What are the effects of sociodemographic factors on the use of outpatient mental health services when different demographic groups have identical health insurance coverage? The authors answer this question using data from the Rand Health Insurance Experiment. Health insurance was randomly assigned to families representative of the nonaged, noninstitutionalized civilian population in six U.S. sites. Income has no significant total effect on use when all income groups have the same coverage. When the effects of variables correlated with socioeconomic status are removed, users with higher socioeconomic status are significantly more likely to choose a mental health specialist rather than only general medical providers for their mental health care (P less than 0.05); among those who visit mental health specialists, those with higher socioeconomic status incur significantly greater expenses (P less than 0.10). Women use significantly more mental health services than men (P less than 0.05), who in turn use significantly more mental health services than children (P less than 0.05), even after controlling for demographic factors, health status, and insurance coverage. Similarly, there are large differences (roughly sixfold) by site in outpatient mental health expenses even when all sites have identical coverage.     

Monitoring aminoglycoside therapy

The aminoglycoside antibiotics are indispensible therapeutic agents; however, a high incidence of toxic effects mandates that they be used with caution. In many patients, careful monitoring of serum concentrations is required. Because of their chemical characteristics, aminoglycosides are given parenterally except in certain well-defined clinical situations such as bowel preparation prior to surgery. The drugs act by interfering with microbial protein synthesis and are uniformly bactericidal. Plasmid-mediated resistance remains a problem, particularly in the hospital environment. Aminoglycosides find their most frequent use in infections caused by aerobic gram-negative bacilli. The pharmacokinetics have been well characterized, and an appropriate dosage regimen can be selected to achieve peak bactericidal levels while maintaining trough concentrations low enough to minimize toxicity. Monitoring of serum aminoglycoside concentrations is essential in many types of patients, such as those having compromised renal function, those receiving a maximum dose of the drug, the obese, the elderly, and patients with cystic fibrosis. Close cooperation between the clinical laboratory and all groups involved in the patient's care is necessary to make maximum clinical use of drug monitoring information.     

Health care access and use among handicapped students in five public school systems

The authors studied the health care access and utilization patterns for a stratified random sample of 1,726 special education students in five large metropolitan school systems. Overall, 7% of the special education students had no regular source of care, 26% had no regular physician, and 38% had not visited a physician in the previous year; 13% had no health insurance. Each of these measures was worse for nonwhite and poorer children as well as for those whose mothers who had less formal education. Insurance coverage was associated with physician visits, with 45% of the uninsured children visiting a physician compared with 63% of those with public insurance and 66% of those with private insurance. Odds ratios for all health care access and use measures showed striking geographic variations. Thus, even for children identified as handicapped by their communities, barriers to health care are evident and are significantly greater for groups traditionally at risk.     

Automated antibiotic susceptibility testing: comparative evaluation of four commercial systems and present state

Automation of AST has come quite some way and is here to stay. In particular, fully automated, "hands off" instruments have great appeal to laboratories with a limited number of well-trained and experienced clinical microbiology personnel. None of the evaluated instruments is perfect, but then neither are the standard or reference techniques. Overnight incubation has been the yardstick since the early days of in vitro AST. Given the usually shorter therapeutic intervals of 4- to 12-hour dosage schedules, it is quite possible that shorter incubation times for in vitro tests will become more of a standard. Until that time, newer, including automatic, techniques need to be evaluated against the more traditional standard methods. Quality control is critical, and since no systematic approach aside from individual manufacturers' suggestions exists, it should be developed by the NCCLS or similar agencies. Quality control might include standards for the evaluation of such equipment and systems because the development of new technology in this area will continue. Overall, reproducibility and accuracy of the instruments and methods evaluated were quite promising and should encourage well-designed studies of clinical correlation and relevance. The AMS equipment has been in use for routine AST in the clinical laboratories of the Seattle Veterans Administration Medical Center and the University of Washington Hospital. Because of its simplicity and flexibility, the Kirby-Bauer method continues to be an alternate technique for certain important clinical isolates, for instance, blood cultures in both laboratories. Finally, it should be remembered that the most critical function of all such equipment is the reliable detection of resistance.     

细节管理在消毒供应中心外来器械消毒中的应用

目的:探讨外来器械在消毒供应中心的细节管理,保证每一件消毒灭菌物品合格率为100%。方法:对外来器械从准入、回收、分类、清洗、消毒、干燥、检查、包装、灭菌、监测、发放等各个环节进行规范化、科学化、细致化管理,保证了手术器械的清洗灭菌质量。结果:外来器械及物品均符合卫生部有关医院感染管理质量标准要求。结论:规范了工作流程和质量控制系统,完善了质量监控和追溯制度,顺应了医院发展骨科的需要,达到了资源共享,节约了成本,满足了临床需要。