Nursing resources and patient outcomes in intensive care: a systematic review of the literature

Objectives

To evaluate the empirical evidence linking nursing resources to patient outcomes in intensive care settings as a framework for future research in this area.

Background

Concerns about patient safety and the quality of care are driving research on the clinical and cost-effectiveness of health care interventions, including the deployment of human resources. This is particularly important in intensive care where a large proportion of the health care budget is consumed and where nursing staff is the main item of expenditure. Recommendations about staffing levels have been made but may not be evidence based and may not always be achieved in practice.

Methods

We searched systematically for studies of the impact of nursing resources (e.g. nurse-patient ratios, nurses’ level of education, training and experience) on patient outcomes, including mortality and adverse events, in adult intensive care. Abstracts of articles were reviewed and retrieved if they investigated the relationship between nursing resources and patient outcomes. Characteristics of the studies were tabulated and the quality of the studies assessed.

Results

Of the 15 studies included in this review, two reported a statistical relationship between nursing resources and both mortality and adverse events, one reported an association to mortality only, seven studies reported that they could not reject the null hypothesis of no relationship to mortality and 10 studies (out of 10 that tested the hypothesis) reported a relationship to adverse events. The main explanatory mechanisms were the lack of time for nurses to perform preventative measures, or for patient surveillance. The nurses’ role in pain control was noted by one author. Studies were mainly observational and retrospective and varied in scope from 1 to 52 units. Recommendations for future research include developing the mechanisms linking nursing resources to patient outcomes, and designing large multi-centre prospective studies that link patient's exposure to nursing care on a shift-by-shift basis over time.     

Use of a Combination of Ankle Pressure and SENSERite System to Treat Older Adults With Impaired Ankle Proprioception: A Single-Blind Experimental Study

You JH, Saliba S, Saliba E. Use of a combination of ankle pressure and SENSERite system to treat older adults with impaired ankle proprioception: a single-blind experimental study.

Objective

To investigate the effects of a combination of visual biofeedback and ankle pressure on ankle position sense in elderly adults with and without impaired ankle joint position sense (JPS).

Design

Independent 2 × 3 factorial design with an experimenter-blind study.

Setting

University motion laboratory.

Participants

Older adults (N=40) were recruited from local community centers. Among them, 21 elderly subjects had relatively normative score, whereas 19 subjects had impaired ankle position sense.

Intervention

Both the normative and impaired elderly subjects underwent either ankle JPS visual feedback training alone or a combination of ankle JPS visual feedback training and circumferential ankle pressure for one 30-minute training session.

Main Outcome Measures

The outcome measures included ankle JPS errors measured in absolute constant error (ACE) and variable error (VE) during standing at pretest, posttest, and 1-week follow-up test. A separate repeated measures analyses of variance was performed to evaluate the differential training effects on ACE and VE, respectively. The Pearson chi-square test and Bonferroni test were performed. Significance was assigned at P less than .05 for all analyses.

Results

Regardless of intervention conditions, older adults with and without ankle position sense impairment showed immediate treatment benefits, which relatively remained stable even at the follow-up test. These effects were reflected in significant improvements of JPS accuracy and consistency (P<.05).

Conclusions

Our findings may suggest that both interventions were equally effective in increasing ankle JPS accuracy and consistency in older adults with and without impairments, and therapeutic effects lasted for a week, reflecting long-term effect.     

Exploratory Study on Oxygen Consumption On-kinetics During Treadmill Walking in Women With Systemic Lupus Erythematosus

Keyser RE, Rus V, Mikdashi JA, Handwerger BS. Exploratory study on oxygen consumption on-kinetics during treadmill walking in women with systemic lupus erythematosus.

Objective

To determine whether oxygen consumption (V˙o₂) on-kinetics differed between groups of women with systemic lupus erythematosus (SLE) and sedentary but otherwise healthy controls.

Design

Exploratory case-control study.

Setting

Medical school exercise physiology laboratory.

Participants

Convenience samples of women with SLE (n=12) and sedentary but otherwise healthy controls (n=10).

Intervention

None.

Main Outcome Measures

V˙o₂ on-kinetics indices including time to steady state, rate constant, mean response time (MRT), transition constant, and oxygen deficit measured during bouts of treadmill walking at intensities of 3 and 5 metabolic equivalents (METs).

Results

Time to steady state and oxygen deficit were increased and rate constant was decreased in the women with SLE compared with controls. At the 5-MET energy demand, the transition constant was lower and MRT was longer in the women with SLE than in controls. For a similar relative energy expenditure that was slightly lower than the anaerobic threshold, the transition constant was higher in controls than in women with SLE.

Conclusion

V˙o₂ on-kinetics was prolonged in women with SLE. The prolongation was concomitant with an increase in oxygen deficit and may underlie performance fatigability in women with SLE.     

Use of cyst fluid CEA, CA19-9, and amylase for evaluation of pancreatic lesions

Objectives

The study goals were development of reference intervals and an interpretive algorithm for pancreatic cyst fluid tumor markers.

Design and methods

442 pancreatic cyst fluids were tested for CEA, CA19-9, and amylase.

Results

CEA > 30 ng/mL discriminates mucinous from non-mucinous cysts. After CEA analysis, amylase and CA19-9 segregate non-mucinous and mucinous subtypes, respectively.

Conclusions

Pancreatic cyst fluid tumor markers supplement other diagnostic measures. This study provides estimated reference intervals and an algorithm for interpretation.     

Patient dignity in an acute hospital setting: a case study

Background

Nurses have a professional duty to respect patients’ dignity. There is a dearth of research about patients’ dignity in acute hospital settings.

Objective

The study investigated the meaning of patient dignity, threats to patients’ dignity, and how patient dignity can be promoted, in acute hospital settings.

Design

A qualitative, triangulated single case study design (one acute hospital), with embedded cases (one ward and its staff, and 24 patients).

Setting

The study was based on a 22-bedded surgical ward in an acute hospital in England.

Participants

Twenty-four patients, aged 34-92 years were purposively selected. There were 15 men and 9 women of varied socio-economic backgrounds. They could all communicate verbally and speak English. Twelve patients, who had stayed in the ward at least 2 days, were interviewed following discharge. The other 12 patients were observed and interviewed on the ward. The ward-based staff (26 registered nurses and healthcare assistants) were observed in practice. 13 were interviewed following observation. Six senior nurses were purposively selected for interviews.

Methods

The data were collected during 2005. The Local Research Ethics Committee gave approval. Unstructured interviews using topic guides were conducted with the 24 patients, 13 ward-based staff and 6 senior nurses. Twelve 4-h episodes of participant observation were conducted. The data were analysed thematically using the framework approach.

Findings

Patient dignity comprised feelings (feeling comfortable, in control and valued), physical presentation and behaviour. The environment, staff behaviour and patient factors impacted on patient dignity. Lack of environmental privacy threatened dignity. A conducive physical environment, dignity-promoting culture and other patients’ support promoted dignity. Staff being curt, authoritarian and breaching privacy threatened dignity. Staff promoted dignity by providing privacy and interactions which made patients feel comfortable, in control and valued. Patients’ impaired health and older age rendered them vulnerable to a loss of dignity. Patients promoted their own dignity through their attitudes (rationalisation, use of humour, acceptance), developing relationships with staff and retaining ability and control.

Conclusion

Patients are vulnerable to loss of dignity in hospital. Staff behaviour and the hospital environment can influence whether patients’ dignity is lost or upheld.     

Predicting Fitness to Drive in People With Cognitive Impairments by Using DriveSafe and DriveAware

Kay LG, Bundy AC, Clemson LM. Predicting fitness to drive in people with cognitive impairments by using DriveSafe and DriveAware.

Objectives

To examine the psychometric properties of DriveSafe and DriveAware and their predictive validity.

Design

Prospective study compared screening tests with criterion standard.

Setting

Two driving rehabilitation centers affiliated with a university and a geriatric rehabilitation facility.

Participants

Consecutive sample of drivers with functional impairments (n=115) and subgroup of drivers with cognitive impairments (n=96) referred for a driving assessment.

Interventions

Not applicable.

Main Outcome Measure

Driving performance was measured by a standardized assessment in real traffic.

Results

Rasch analysis provided evidence for construct validity and internal reliability of both tests. Tests trichotomized drivers into unsafe, safe, and further testing categories. The optimal lower cutoff identified unsafe drivers with a specificity of 97% (95% confidence interval [CI], 83-100) in the test sample and 96% (95% CI, 80-100) in the validation sample. The optimal upper cutoff identified safe drivers with a sensitivity of 93% (95% CI, 77-99) and 95% (95% CI, 76-100), respectively.

Conclusions

By using DriveSafe and DriveAware, drivers with cognitive impairments referred for a driving assessment can be categorized as unsafe, safe, or requiring further testing, with only 50% needing an on-road assessment. Before clinical practice is changed, these findings should be replicated.     

Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study

Background

Pressure ulcers are common in acute and long-term care. However, critically ill patients usually have multiple risk factors for pressure ulcers.

Objectives

The study was conducted to assess pressure ulcer incidence in intensive care patients, the factors related to pressure ulcer incidence and the course of pressure ulcers after the admission to an intensive care unit.

Design

A longitudinal design.

Setting

This study was carried out in cardiological and surgical intensive care of a general hospital and in a nephrological intensive care of a university hospital.

Participants

All patients admitted to intensive care wards during the period from April until October 2006 were invited to take a part in the study. One hundred and twenty-one patients were involved in the study. The inclusion criteria were adult intensive care patients, males and females, all diagnosis were included. The exclusion criterion was patients whose age less than 18 years.

Method

Each patient was assessed twice; first, upon admission and second upon discharge or death, or after 2 weeks if the patient was still in intensive care. The assessed data included pressure ulcer preventive measures, risk factors using Braden score, pressure ulcer characteristics and treatment. Additionally, incontinence supplies (urine/bowel) if used and the severity of illness using Acute Physiology and Chronic Health Evaluation (APACHE II score) were assessd.

Results

This study revealed a total incidence of 3.3% (4.5% in nephrological patients and 2.9% in surgical patients). Sixteen patients with a total of 21 pressure ulcers were admitted to the intensive care units. During the patients’ stay at the intensive care units six pressure ulcers developed newly and five pressure ulcers healed. The mean of the APACHE II score of patients with new pressure ulcers (16.6) were higher than in patients without new pressure ulcers (11.5).

Conclusion

Pressure ulcer incidence is low in this study compared to other studies. Pressure ulcers can be healed in intensive care patients. Using some preventive measures such as foam and alternating air pressure mattresses may help to decrease pressure ulcer development. Hydrocolloid dressing may help to increase the healing rate of pressure ulcers.     

Responsiveness of Mobility, Daily Living, and Instrumental Activities of Daily Living Outcome Measures for Geriatric Rehabilitation

Demers L, Desrosiers J, Nikolova R, Robichaud L, Bravo G. Responsiveness of mobility, daily living, and instrumental activities of daily living outcome measures for geriatric rehabilitation.

Objectives

To assess and compare the ability of the Timed Up & Go (TUG) and subscales of the Functional Autonomy Measurement System (SMAF) to detect change in people undergoing geriatric rehabilitation in inpatient geriatric rehabilitation units (GRUs) and day hospitals.

Design

Longitudinal design with repeated measures obtained at admission and discharge from rehabilitation and at 2 follow-up interviews.

Setting

Inpatient and outpatient hospital-based settings.

Participants

Subjects (N=237, age 80±7y) had data at admission and discharge from rehabilitation (changing time frame), and of these, 160 had data at 2 subsequent follow-ups (stable time frame).

Interventions

Not applicable.

Main Outcome Measures

The TUG was used to estimate basic mobility, and subscales of the SMAF were used to estimate general mobility (SMAF-mobility), basic activities of daily living (SMAF-ADL), and instrumental activities of daily living (SMAF-IADL). Professionals' perception of change was used as a criterion.

Results

The TUG generated large values for the standardized response mean (SRM) and Guyatt's responsiveness index in GRUs (.98 and 1.12) and day hospitals (.89 and 1.85). Professionals' perception of change in mobility was explained by a perceptible change in the TUG in day hospitals (15%) but not in GRUs. The SMAF-mobility, SMAF-ADL, and SMAF-IADL were associated with large values of SRM and Guyatt's responsiveness index in GRUs (.97-2.17) and with small to moderate values in day hospitals (.29-.54). Moderate to large portions in the professionals' perceptions of change for mobility (20%, 17%), basic ADLs (10% and 14%), and IADLs (23% and 19%) were associated with the respective change scores of the subscales of the SMAF in both GRUs and day hospitals.

Conclusions

Progress of older adults in the areas of mobility, basic ADLs, and IADLs can be captured using the TUG, SMAF-mobility, SMAF-ADL, and SMAF-IADL in both GRUs and day hospitals. The results support their use in settings of high- and low-intensity rehabilitation, thus suggesting their adequacy for use in these 2 settings.     

Value of Functional Capacity Evaluation Information in a Clinical Setting for Predicting Return to Work

Streibelt M, Blume C, Thren K, Reneman MF, Mueller-Fahrnow W. Value of functional capacity evaluation information in a clinical setting for predicting return to work.

Objective

To evaluate the quality of Functional Capacity Evaluation (FCE) information in predicting return to work (RTW).

Design

Prospective cohort study.

Setting

Inpatient rehabilitation clinic.

Participants

Patients (N=220) with chronic musculoskeletal disorders (MSD) conducting a medical rehabilitation.

Interventions

Not applicable.

Main Outcome Measures

Patients filled in questionnaires at admission and 1-year follow-up. An FCE was performed on admission. RTW was defined as a combination of employment at 1-year follow-up with a maximum of 6 weeks sick leave because of MSD in the postrehabilitation year. As predictive FCE information, the physical capacity (Dictionary of Occupational Titles categories 1-5), the number of test results not meeting work demands (0-25), and the tester's recommendation of work ability in the actual job (≥6h/d) were analyzed. Logistic regression models (crude and adjusted for the concurrent predictors employment, preadmission sick leave, and patient's prognosis of RTW) were created to predict RTW.

Results

Complete data were obtained for 145 patients. The sample showed a non-RTW at 1-year follow-up for 37.9%. All FCE information showed significant relations to RTW (r=.28-.43; P<.05). In the crude as well as in the adjusted regression models, all FCE information predicted RTW, but the models' quality was low. The integration of FCE information led to an increase of 5%. The predictive efficiency was poor. The adjusted model for failed tests showed a substantial improvement compared with the reference model (concurrent predictors only).

Conclusions

There was a significant relation between FCE information and RTW with and without concurrent predictors, but the predictive efficiency is poor. Primarily, the number of failed tests seemed to be of significance for patients with ambiguous RTW prognosis. A first proposal for a prediction rule was discussed.     

Effects of ankle joint mobilizations in adults poststroke: a pilot study

Kluding PM, Santos M. Effects of ankle joint mobilizations in adults poststroke: a pilot study.

Objective

To compare the effect of 2 interventions on ankle mobility, ankle kinematics, and weight-bearing symmetry during functional activities in subjects with hemiparesis after a stroke.

Design

Randomized trial.

Setting

Academic medical center.

Participants

A convenience sample of 16 subjects with hemiparesis after stroke (mean age, 55.2y; mean time since stroke, 21.4mo).

Intervention

Subjects received 8 sessions over 4 weeks of either functional task practice combined with ankle joint mobilizations, or functional task practice only.

Main Outcome Measures

Changes in ankle range of motion (ROM) (not blinded), ankle kinematics during sit-to-stand (STS) and gait, and lower-extremity weight-bearing symmetry during STS and static standing.

Results

The combined intervention group gained 5.7°±3.1° in passive ankle ROM compared with 0.2°±2.6° in the functional practice only group (95% confidence interval [CI], 2.5-8.6; P<.01). No significant changes in ankle kinematics or weight bearing during static standing were noted in either group. The functional practice group decreased differences in weight bearing during STS by 9.5%±6.47%, whereas the combined intervention group increased this difference by 3.37%±5.29% (95% CI, 3.26-19.46; P=.01).

Conclusions

The increase in ankle motion did not improve joint kinematics and may have prevented improvement in weight-bearing symmetry.