Is there a preferred technique for weaning the difficult-to-wean patient? A systematic review of the literature

OBJECTIVE: To answer the following question: In difficult-to-wean patients, which of the three commonly used techniques of weaning (T-piece, synchronized intermittent mandatory ventilation, or pressure support ventilation) leads to the highest proportion of successfully weaned patients and the shortest weaning time? DATA SOURCES: Computerized literature searches in MEDLINE (1975-1996), Cinahl (1982-1996), and Healthplan (1985-1996), exploding all Mesh headings pertaining to Mechanical Ventilation and Weaning. Searches were restricted to the English language, adults, and humans. Personal files were hand searched, and references of selected articles were reviewed. STUDY SELECTION: a) Population: Patients requiring a gradual weaning process from the ventilator (either requiring prolonged initial ventilation of >72 hrs or a failed trial of spontaneous breathing after >24 hrs of ventilation); b) Interventions: At least two of the following three modes of weaning from mechanical ventilation must have been compared: T-piece, synchronized intermittent mandatory ventilation, or pressure support ventilation; c) Outcomes: At least one of the following: weaning time (time from initiation of weaning to extubation) or successful weaning rate (successfully off the ventilator for >48 hrs); and d) Study design: Controlled trial. DATA EXTRACTION: Two reviewers independently reviewed the articles and graded them according to their methodologic rigor. Data on the success of weaning and the time to wean were summarized for each study. DATA SYNTHESIS: The search strategy identified 667 potentially relevant studies; of these, 228 had weaning as their primary focus, and of these, 48 addressed modes of ventilation during weaning. Only 16 of these 48 studies had one of the specified outcomes, and only ten of these were controlled trials. Of the ten trials, only four fulfilled all our selection criteria. The results of the trials were conflicting, and there was heterogeneity among studies that precluded meaningful pooling of the results. CONCLUSIONS: There are few trials designed to determine the most effective mode of ventilation for weaning, and more work is required in this area. From the trials reviewed, we could not identify a superior weaning technique among the three most popular modes, T-piece, pressure support ventilation, or synchronized intermittent mandatory ventilation. However, it appears that synchronized intermittent mandatory ventilation may lead to a longer duration of the weaning process than either T-piece or pressure support ventilation. Finally, the manner in which the mode of weaning is applied may have a greater effect on the likelihood of weaning than the mode itself.     

Nurse Leaders’ Influence: Implementing a New Model of Care Involving Geographic Clustering of Patient Care Assignments

The purpose of this article is to describe the nurse leader’s role in implementing a new evidence-based nursing care delivery model utilizing geographic clustering of patient care assignments to improve patient safety and patient experience. Nurse leaders on 2 inpatient units from an academic medical center supported and encouraged staff to develop and initiate similar care models; one unit focused on fall reduction, the other focused on improving patient experience. The transformational nurse leaders empowered key stake holders to implement a new and creative care model that resulted in favorable outcomes for both patients and staff, while fostering accountability for the practice change.     

Is employee discipline the solution for patient safety?

Explore alternative solutions to discipline and address ways to achieve patient safety without penalizing employees.     

AIDS and a New Generation of Orphans: Is There a Role for Group Care?

SUMMARY

The AIDS epidemic, now ending its second decade, has created challenges, controversy, and occasionally change. In the early years adults were the primary, and usually the only, focus of attention. Policies and practices affecting children were addressed primarily in relation to HIV-infected infants and young children. Their needs for medical care, foster homes, and nurturing were the focus of specially created private and public programs.

Only in the past several years has the long-term impact of the AIDS epidemic on children and adolescents living with an HIV-infected parent or orphaned as a result of the parent's death come to public and professional attention. Like other aspects of the epidemic, questions about the care and custody of these vulnerable children and youth began to be addressed only after the problem had reached crisis proportions. Also like other aspects of the epidemic, these issues have created challenges, controversy, and occasionally change.

This article introduces one subject that has to date received no sustained analysis: the potential role of group care options for children, youth, and families struggling with the impact of AIDS. This subject has been avoided by both child welfare specialists and AIDS service providers; one barrier to discussion has been history-or to be more precise, oversimplified history. To turn Santayana's well-known dictum on its head, in this case the fear of repeating the past has condemned us to fail to learn from it.     

Issues of Diagnosis and Care For The Transgender Patient: Is the DSM-5 on Point?

The experience of individuals who happen to be transgender is one that reflects a complex constellation of powerful influences both within and outside of the health care system in the United States. Profound stigma, prejudice, misunderstanding, and hate for these individuals are just a few examples of the formidable challenges that potently shape their lives. The combination of exposed vulnerabilities in the expression of their true selves, and the often hostile environment where this transformation occurs creates the perfect storm for the onset of serious psychiatric illnesses. Oddly enough, the pathology is often not wrought in the experience of the genuine self but more so in what happens to that self in the context of a violent environment. This article explores these factors in the context of psychiatric diagnosis in the DSM-5.     

Issues of Diagnosis and Care For The Transgender Patient: Is the DSM-5 on Point?

The experience of individuals who happen to be transgender is one that reflects a complex constellation of powerful influences both within and outside of the health care system in the United States. Profound stigma, prejudice, misunderstanding, and hate for these individuals are just a few examples of the formidable challenges that potently shape their lives. The combination of exposed vulnerabilities in the expression of their true selves, and the often hostile environment where this transformation occurs creates the perfect storm for the onset of serious psychiatric illnesses. Oddly enough, the pathology is often not wrought in the experience of the genuine self but more so in what happens to that self in the context of a violent environment. This article explores these factors in the context of psychiatric diagnosis in the DSM-5.     

Is There a Biological Basis for the Clustering of Symptoms?

OBJECTIVES: To examine symptom clusters in oncology patients; to determine if these symptom clusters might share a common biologic mechanism; and to describe potential biologic mechanisms that warrant investigation. DATA SOURCES: Synthesis of the theoretical and research papers on symptom clusters. CONCLUSION: Definitive conclusions about whether there is a biologic basis for the clustering of symptoms cannot be determined at this time. The animal model of sickness behavior holds promise as a potential biologic mechanism for clustering symptoms. IMPLICATIONS FOR NURSING PRACTICE: Until more definitive studies of symptom clusters are performed, clinicians need to monitor patients for the co-occurrence of multiple symptoms and develop appropriate management plans.     

Is ghrelin a signal for the development of metabolic systems?

Ghrelin, produced in the stomach, acts on growth hormone secretagogue receptors (GHSRs) in hypothalamic neurons to potently increase food intake. However, male mice with deletions of ghrelin (Ghrl-/- mice) or GHSR (Ghsr-/- mice) display normal growth and regulation of food intake. Furthermore, adult Ghrl-/- mice display a normal sensitivity to high-fat diet-induced obesity. These findings from early studies raised the question as to whether the ghrelin system is an essential component for the regulation of food intake and body weight homeostasis. However, recent studies by Wortley et al. and Zigman et al. demonstrate that Ghrl-/- and Ghsr-/- mice are resistant to diet-induced obesity when fed a high-fat diet during the early post-weaning period. This commentary highlights 3 key issues raised by these 2 reports: (a) the impact of ghrelin on the development of metabolic systems; (b) the constitutive activity of GHSR; and (c) gender differences in the sensitivity to deletion of the ghrelin signaling system.     

Is patient satisfaction a legitimate outcome of pain management?

Though many studies have measured patient satisfaction with pain management using the American Pain Society (APS) Satisfaction Survey or its variants, little is known about the relationship among the survey items, or whether items relate to satisfaction at all. In an effort to refine the measurement of patient satisfaction, a modified version of the APS survey, which was given to 787 patients as part of a study of postoperative pain management in six community hospitals, was subjected to principal components analysis to determine the survey's empirical structure. Correlations among the five components found were low; a weak relationship (r = -0.24) was discovered between pain intensity and satisfaction. A heuristic model estimated by structural equations analysis yielded additional insights. Though many items thought to influence patient satisfaction were not closely related to patient-reported satisfaction, they indicate important clinical factors relevant to quality of care, and thus, to continuing quality improvement (CQI) efforts. Results suggest that satisfaction was influenced by effectiveness of medication, independent of pain intensity, and by communication. Pain severity ratings near the time satisfaction was measured were more influential than earlier ratings.