Establishment of stroke treatment plans: one hospital's experience.

Stroke remains one of the major causes of death and permanent disability in the United States, ranking as the third leading cause of death behind heart disease and cancer. It affects an estimated 700,000 persons each year; about two-thirds of those with a new or recurrent stroke survive. The aggregate cost of stroke in the United States is more than $40 billion per year, with an average cost per case of approximately $50,000. With the advent of recombinant tissue-type plasminogen activator (t-PA) for acute stroke, clinical pathways have been developed to provide efficient care to acute stroke patients. Efforts must be aimed at educating the public and all members of the healthcare team about proper stroke care. Surprisingly, only 20%-30% of all hospitals have stroke teams in place. To bring stroke care into the 21st century, this deficiency must be addressed and additional treatment agents such as neuroprotective medications need to be approved.     

Documentation of model-based practice: one hospital's experience

Nursing conceptual models have been useful tools to guide clinical practice. They help define nursing as well as provide a consistent and efficient means of communication within the profession. One of the greatest challenges in implementing the use of a nursing conceptual model is adjusting current documentation to reflect the model appropriately. When the Neuman Systems Model was adopted as the nursing conceptual model to be implemented at our institution, we faced this challenge. Throughout the process of implementation, various documents were revised or created, including the Pediatric Admission Database and the Neuman Process Summary. In addition, registered nurses were educated on how to improve documentation in order to better use the concepts of the model.     

Respiratory care practitioners as secondary providers of endotracheal intubation: one hospital's experience

The management staff of the Respiratory Care Department at the suggestion of the Department of Anesthesiology determined that there was a need for respiratory care practitioners (RCPs) to be trained to perform endotracheal intubation. This need was demonstrated by the frequency with which anesthesia personnel were called away from the operating room (OR) to perform endotracheal intubations in other hospital areas. METHODS: The training program included didactic instruction followed by written examination, simulations, and intubation experience in the OR under the direct supervision of a staff anesthesiologist. RESULTS: Initially 15 therapists, from all shifts were trained. Currently, there are 20 fully-trained RCPs on staff. These therapists have successfully intubated 160 patients in 178 attempts over a 49 month period. All attempts followed failed attempts by other professionals. No major complications were observed in the patients intubated by RCPs. DISCUSSION: This training program has successfully provided support for endotracheal intubation procedures, sparing the anesthesiology staff and expanding the role of RCPs in our hospital.     

Autologous transfusion: a community blood bank experience

Interest in the use of autotransfusion has increased greatly, as can be ascertained by looking at usage patterns and literature citations when compared to recent past years. In this paper, we discuss different autotransfusion methods, as well as the clinical experience of a community blood bank over a 3 1/2-year period with predeposited autologous transfusions for elective surgical procedures. Blood collected in Adenine-Saline (AS-1) preservatives allows up to 42 days of storage in liquid state after donation. An average of 2.4 units per donor-patient were drawn, with almost two thirds of them being reinfused during or immediately after surgery. Even though the results of cost analysis and efficiency are far from optimal, autologous transfusion remains an effective albeit expensive alternative to homologous transfusion.     

Implementation of a pediatric trauma massive transfusion protocol: one institution's experience

BACKGROUND: Massive transfusion protocols (MTPs) with fixed ratios of blood products may improve outcomes in coagulopathic adult trauma patients. However, there is a paucity of data on transfusion support protocols for pediatric trauma patients, whose mechanisms of injury may differ from those seen in adults. We hypothesized that an MTP would improve outcomes in children, through a balanced blood product resuscitation. STUDY DESIGN AND METHODS: A pediatric trauma MTP, with a fixed ratio of red blood cells (RBCs) : fresh‐frozen plasma (FFP) : platelets : cryoprecipitate in quantities based on the patient's weight, was initiated at a pediatric hospital. Data on clinical status, resuscitation volumes, and hospital course were collected and compared to data from pre‐MTP trauma patients requiring transfusion. RESULTS: Fifty‐three patients were enrolled over a 15‐month period and compared to 49 pre‐MTP patients. Seventy‐two percent of MTP patients had at least one coagulation value outside of the normal range upon emergency department (ED) arrival, and the median time to FFP transfusion decreased fourfold after MTP implementation (p < 0.0001). A total of 49% of MTP patients received greater than 70 mL/kg blood products, and the 24‐hour median FFP : RBC transfusion ratio was twofold higher in these patients than the pre‐MTP cohort (median, 1:1.8 vs. 1:3.6; p = 0.002). No improvement in mortality was observed after MTP implementation, taking into consideration injury severity, prothrombin time, and partial thromboplastin time. CONCLUSIONS: A pediatric trauma MTP is feasible and allows for rapid provision of balanced blood products for transfusion to coagulopathic children. Larger studies are warranted to determine whether such protocols will improve outcomes for pediatric trauma patients.     

Intraoperative blood glucose management: impact of a real-time decision support system on adherence to institutional protocol

Poor perioperative glycemic management can lead to negative surgical outcome. Improved compliance to glucose control protocol could lead to better glucose management. An Anesthesia Information Management System based decision support system—Smart Anesthesia Manager? (SAM) was used to generate real-time reminders to the anesthesia providers to closely adhere to our institutional glucose management protocol. Compliance to hourly glucose measurements and correct insulin dose adjustments was compared for the baseline period (12 months) without SAM and the intervention period (12 months) with SAM decision support. Additionally, glucose management parameters were compared for the baseline and intervention periods. A total of 1587 cases during baseline and 1997 cases during intervention met the criteria for glucose management (diabetic patients or non-diabetic patients with glucose level >140 mg/dL). Among the intervention cases anesthesia providers chose to use SAM reminders 48.7 % of the time primarily for patients who had diabetes, higher HbA1C or body mass index, while disabling the system for the remaining cases. Compliance to hourly glucose measurement and correct insulin doses increased significantly during the intervention period when compared with the baseline (from 52.6 to 71.2 % and from 13.5 to 24.4 %, respectively). In spite of improved compliance to institutional protocol, the mean glucose levels and other glycemic management parameters did not show significant improvement with SAM reminders. Real-time electronic reminders improved intraoperative compliance to institutional glucose management protocol though glycemic parameters did not improve even when there was greater compliance to the protocol.     

Integrating disaster preparedness into a community health nursing course: one school's experience.

It is not practical to wait for a disaster, whether natural or human-made, to learn how to respond and provide specialized care. The Long Island University School of Nursing in Brooklyn, New York, has developed a specific educational experience for undergraduate nursing students enrolled in community health. The course is offered in the senior semester and includes didactic material based on the International Nursing Coalition for Mass Casualty Education-recommended competencies. Students are given the opportunity to apply the learning and develop additional skills by participating in a mock drill. Although anecdotal comments from the students indicate that the coursework has been helpful, additional research is planned to evaluate the program.     

血糖数据化管理对社区2型糖尿病患者血糖控制影响的研究

目的通过血糖数据化管理对社区2型糖尿病患者血糖控制的监测及干预,探讨糖尿病健康管理的方法。方法选取荆门市城区某社区125例2型糖尿病患者,对其进行血糖数据化管理干预,对比实施前和实施5个月后患者的体质量指数、空腹血糖、餐后2 h血糖、糖化血红蛋白的控制情况。结果血糖数据化管理干预5个月后,患者的体质量指数、空腹血糖、餐后2 h血糖、糖化血红蛋白的控制情况优于干预前(P0.01)。结论通过血糖数据化管理,社区2型糖尿病患者可获得更好的血糖控制。