Factors associated with complementary medicine use in pediatric musculoskeletal conditions: Results from a national survey

ObjectivesComplementary and alternative medicine (CAM) use is common in children, but its use has only been investigated in children with musculoskeletal conditions (MSK) to a limited extent. We aimed to characterize factors associated with CAM use in children with MSK conditions.MethodsWithin the 2012 National Health Interview Survey dataset (including its child CAM supplement), we examined factors associated with CAM use in children with MSK conditions and performed an analysis examining the perceived usefulness of CAM therapies for MSK conditions.ResultsOverall, there were 10,218 children in the dataset. 28.0% of children with MSK conditions used CAM, compared to 8.8% of children without MSK conditions. Gender (p = 0.003), region (p = 0.001), race (p = 0.001), parental CAM use (p < 0.001), education (<0.001), and having anxiety, stress or depression (p = 0.030) were correlated with CAM use. Among 90 children who reported on CAM use, 89.7% said that CAM helped some or a great deal for their MSK condition.ConclusionsSeveral factors, particularly parental education and parental CAM use, were associated with CAM use, and self-reported improvement rates were high. Interventional trials are needed to determine the efficacy of specific CAM therapies for treating different MSK conditions in children.     

Use of electronic personal health records (PHRs) for complementary and alternative medicine (CAM) disclosure: Implications for integrative health care

ObjectivesTo test a hypothesis that patients' use of Internet-based personal health records (PHRs) will be positively related to their disclosure of their CAM use to medical doctors, controlling for covariates' effects (e.g., health, human capital, and demographics), and to examine the factors influencing patients' CAM use disclosures.DesignCross-sectional survey.MethodsWe analyzed data in a subsample of CAM users who used both the internet and healthcare services (n = 1457) from the Health Information National Trends Survey, a nationally representative study of U.S. adults (≥18), by using a multivariate logistic analysis.ResultsAmong the subsample, 52.7% disclosed their use of CAM to their doctors and 19.3% used PHRs. Both the bivariate (64.1% vs. 35.9%, p < 0.01) and multivariate (β = 0.558, SE = 0.220, OR = 1.75, p < 0.05) analyses revealed a positive relationship between PHR use and CAM use disclosure. Other significant factors for CAM use disclosure included being older, being a female, having insurance, and having regular source of care. Particularly, foreign-born adults had significantly lower odds of disclosing their CAM use than U.S.-born adults.ConclusionsWe found that patients' PHR use facilitated their disclosure of CAM use to medical doctors. To ensure integrative healthcare and integrative medicine in the healthcare sector and optimum care for patients, education for CAM users regarding PHR adoption is encouraged. Next-generation PHR designs should consider incorporating domains for CAM data that allow patients to store CAM data and also incorporating ‘intelligent' PHRs, whose contents can be converted into the patient's first language.     

Complementary and alternative medicine self-care strategies for nausea in patients undergoing abdominal or pelvic irradiation for cancer: A longitudinal observational study of implementation in routine care

ObjectiveTo longitudinally describe practice of Complementary and Alternative Medicine (CAM) self-care strategies for nausea during radiotherapy.MethodsTwo hundred patients daily registered nausea and practice of CAM self-care strategies, beside conventional antiemetic medications, for nausea during abdominal/pelvic irradiation (median five weeks) for gynecological (69%) colorectal (27%) or other tumors (4%).ResultsDuring radiotherapy, 131 (66%) experienced nausea, and 50 (25%) practiced self-care for nausea at least once, for a mean (m) of 15.9 days. The six of 50 patients who stayed free from nausea practiced self-care more frequent (m = 25.8 days) than the 44 patients experiencing nausea (m = 14.5) (p = 0.013). The CAM self-care strategies were: modifying eating (80% of all self-care practicing patients, 80% of the nauseous patients versus 83% of the patients free from nausea; ns) or drinking habits (38%, 41% vs 17%; ns), taking rests (18%, 20% vs 0%; ns), physical exercising (6%, 2% vs 33%; p = 0.035), acupressure (4%, 5% vs 0%; ns) and self-induced vomiting (2%, 2% vs 0%; ns).ConclusionA fourth of patients undergoing emetogenic radiotherapy practiced CAM self-care for nausea, mostly by modifying eating or drinking habits. The CAM self-care practicing patients who did not become nauseous practiced self-care more frequent than the nauseous patients did. To make such self-care evidence based, we need studies evaluating its efficacy.     

Complementary and alternative medicine for lowering blood lipid levels: A systematic review of systematic reviews

BackgroundThe aim of this article is to summarize and critically evaluate the evidence from systematic reviews (SRs) of complementary and alternative medicine (CAM) for lowering blood lipid levels (BLL).MethodsEight electronic databases were searched until March 2016. Additionally, all the retrieved references were inspected manually for further relevant papers. Systematic reviews were considered eligible, if they included patients of any age and/or gender with elevated blood lipid levels using any type of CAM. We used the Oxman and AMSTAR criteria to critically appraise the methodological quality of the included SRs.ResultsTwenty-seven SRs were included in the analyses. The majority of the SRs were of high methodological quality (mean Oxman score = 4.81, SD = 4.88; and the mean AMSTAR score = 7.22, SD = 3.38). The majority of SRs (56%) arrived at equivocal conclusions (of these 8 were of high quality); 7 SRs (37%) arrived at positive conclusions (of these 6 were of high quality), and 2 (7%) arrived at negative conclusions (both were of high quality). There was conflicting evidence regarding the effectiveness of garlic; and promising evidence for yoga.ConclusionsTo conclude, the evidence from SRs evaluating the effectiveness of CAM in lowering BLL is predominantly equivocal and confusing. Several limitations exist, such as variety of doses and preparations, confounding effects of diets and lifestyle factors, or heterogeneity of the primary trials among others.     

Prevalence and characteristics of Australian women who use prayer or spiritual healing: A nationally representative cross-sectional study

ObjectivesTo determine the prevalence and characteristics of users of prayer or spiritual healing among Australian women aged 31–36 years.Design and settingThis cross-sectional study was conducted as a part of the Australian Longitudinal Study on Women’s Health (ALSWH). The sample used in the current sub-study were participants from the ‘young’ cohort (1973–78) (n = 8180) aged between 31 and 36 years.Main outcome measureUse of prayer or spiritual healingResultsPrayer or spiritual healing was used on a regular basis by 20% of women aged between 31 and 36 years in 2009. Women who had symptoms of chronic illnesses (p = 0.001), women who had never smoked (p = 0.001) and women who used other forms of CAM (p < 0.001) were significantly more likely to use prayer or spiritual healing.ConclusionA significant proportion of women use prayer or spiritual healing on a regular basis. Further research is required to better understand their rationale for using prayer or spiritual healing and its perceived impact on health related outcomes and general well-being.     

Significantly elevated C-reactive protein serum levels are associated with very high 30-day mortality rates in hospitalized medical patients

Background:There is insufficient data regarding the differential diagnosis and the prognostic value of significantly elevated serum levels of C-reactive protein (CRP) in hospitalized medical patients.Design and methods:A retrospective review of medical charts of patients admitted to a tertiary hospital's Internal Medicine ward during a period of 1 year who had at least one CRP serum level measurement of 200 mg/L or more.Results:Overall, 341 patients with a mean age of 69.8 ± 1.0 years were included in the study. Acute infection was the most prevalent diagnosis (n = 293; 85.9%) with community-acquired pneumonia being the most common acute infection (n = 115; 33.7%). Non-infectious conditions accounted for 9.1% (n = 31) of the diagnoses and included mainly malignant metastatic diseases (n = 19; 5.6%). Overall, 70 (20.5%) patients died within 30 days of admission. Age and active malignancy, with metastasis or without metastasis, were independently associated with 30-day mortality.Conclusion:Significantly elevated CRP serum levels are associated with bacterial infections, malignant diseases, and very high rates of 30-day mortality in hospitalized medical patients.     

Development and evaluation of the R-I-CAM-Q as a brief summative measure of CAM utilisation

ObjectiveThis study evaluates a revised version of the I-CAM-Q, the R-I-CAM-Q, which is a shorter scale, and suitable for use as a brief, summative measure of CAM utilisation.DesignOnline survey with an Australian sample (n = 2697).AnalysisThe psychometric properties of the I-CAM-Q were analysed using Mokken Scaling Analysis and Structural Equation Modelling.ResultsA subset of items were identified as having an adequate uni-dimensional structure that can be aggregated to yield a scalar measure of CAM utilisation. Certain items, including prayer for health purposes, and chiropractic, were not indicative of general CAM use.ConclusionsThe R-I-CAM-Q provides a unitary, aggregate measure of CAM utilisation that provides scope for replicable research into the determinants of CAM use. It is the first quantitative and summative measure of general CAM use, developed and tested using modern psychometric methods.     

Emergency department image interpretation accuracy: The influence of immediate reporting by radiology

IntroductionThe misinterpretation of radiographs is recognised as a key source of emergency department (ED) errors, regardless of clinician profession. This article compares ENP and medical staff accuracy in the interpretation of musculoskeletal trauma X-rays between immediate and delayed radiology reporting pathways.MethodThe data for this study was drawn from a larger pragmatic randomized controlled trial of immediate reporting. Patients were recruited and randomly assigned to immediate or delayed reporting arms and treated according to group assignment. Image interpretive accuracy between ED staff groups and arms was undertaken together with an assessment of the influence of immediate reporting on patient pathways and journey times.ResultsSix hundred and seventy-four radiographic examinations were performed (598 patients). There was a significant reduction in the interpretive errors in the immediate reporting arm for all ED clinicians (proportional difference = 4.2%; 95% CI [0.017, 0.068]; p = 0.001), but no significant difference in proportion of interpretive errors was evident between ENPs and medical staff. Patient journey times, discharge and referral rates were not significantly different between study arms, although admission rates varied for medical staff collectively.ConclusionENP X-ray interpretation accuracy is comparable with that of medical staff, but immediate reporting was seen to reduce errors without increasing patient journey times.     

Use of aromatherapy to promote a therapeutic nurse environment

BackgroundWorkplace stress can affect nurse satisfaction. Aroma therapy as a therapeutic use of essential oil can be beneficial in reducing stress.PurposeAssess perceived stress pre-post introduction of Essential Oil Lavender among registered nurses, charge nurses, and patient care technicians in a trauma intensive care unit, surgical specialty care unit and an orthopedic trauma unit.MethodsPre-post intervention with a quasi-experimental design. After a pre-survey, Essential Oil Lavender was diffused 24 h per day over 30 days in a designated nursing area that all nurses were not required to enter on each unit.ResultsDependent sample t-test for “how often do nurses feel stressed a work in a typical week” revealed pre-survey mean 2.97 (SD = 0.99) which was significantly higher than post-survey mean 2.70 (SD = 0.92) with significance, t(69) = 2.36, p = 0.021, suggesting a difference in how often staff felt stressed at work in a typical week, trending down from “feeling stressed half of time” to “once in a while”. There were no statistically significant differences in pre-post survey scores for TICU, TOU, or SSC as separate units.RelevanceUse of essential oils to decrease work-related stress among nursing staff may improve retention, workplace environment, and increase nurse satisfaction.     

Investigation of dietary supplements prevalence as complementary therapy: Comparison between hospitalized psoriasis patients and non-psoriasis patients,correlation with disease severity and quality of life

ObjectivesPsoriasis patients are often displeased with traditional medical treatments and they may self-prescribe dietary supplements as an alternative or complementary treatments. We aimed to investigate the prevalence of self-medication of dietary supplements among psoriasis and non-psoriasis cases and its impact on disease severity and quality of life.Design and settingThis case-control study evaluated 252 records of psoriasis patients and 245 non-psoriasis cases. Dietary supplementation over last 30 days and characteristics, including age, age at onset of disease, co-morbidities, smoking and education were recorded. Psoriasis area and severity index (PASI) and dermatology quality of life index (DLQI) were calculated. P value less than 0.05 was considered as significant level.ResultsThis study consisted 138 psoriasis (females; 54) and 138 non-psoriasis cases (females; 50), aged between 21 and 91 years. Among psoriasis patients, 72% reported using at least one of dietary supplements, which was different from non-psoriasis cases (25.36%, P = 0.01). Multivitamin/mineral supplements (MVM) were the most frequent used dietary supplements (26.81%) and the most common reasons for the consumption of these supplements were to maintain and improve health. The consumption of folic acid (21.73%), omega-3 fatty acids or fish oil (10.14%), herbs (12.31%) and vitamin E (1.44%) had the most frequencies after MVM. No significant differences in PASI and DLQI were found among patients with consumption of different supplements (P > 0.05). There was non-significant and negative correlation between education and use of supplements (P = 0.21, r = −0.02).ConclusionsSelf-medicating of MVM over last 30 days was prevalent among studied psoriasis patients. They took dietary supplements in order to improve and maintain their health.     

Impacto de la ratio paciente-enfermera en los resultados de salud en los hospitales públicos del Servicio Andaluz de Salud. Estudio ecológico

AimTo analyse the patient-nurse ratio and its association with health outcomes in public hospitals of the Andalusian Health Service (SAS).MethodCross-sectional ecological study carried out in adult units of 26 Andalusian public hospitals. Data on structure (beds, type of unit, nursing control), management (average stay, index of use of stays, complexity index) and nursing staff were collected. They were extracted from official sources: CMBDA, SAS/Health Council (CS) publications and specific respondents to Nursing Directorates. The patient-nurse ratio was calculated and related to 19 indicators of hospital quality, safety, and mortality. Measures of central tendency and Spearman's correlation coefficient were used for statistical analysis.ResultsA response was obtained from 100% of the Andalusian hospitals. The average patient-nurse ratio in the three shifts was lower in hospitals with a broader portfolio of services-regional scope (11.6), followed by those with a medium portfolio-specialties (12.7) and hospitals with a basic portfolio- county (13.5). By type of unit, the medical units were 11.8 (SD = 1.8) lower than the surgical ones 13.5 (SD = 2.7). Significant differences were only found in medical units of regional hospitals 10.5 (SD = 1.4) and district hospitals 13.03 (SD = 1.46) (p = .001). In critical care, the ratio was greater than 2 patients per nurse in the three groups. When relating the ratio to health outcomes, 5 significant associations were found: pressure ulcers (p = .005), prevalence of nosocomial infections (p = .036), postoperative sepsis (p = .022), zero bacteraemia verification (p = .045) and mortality from heart failure (p = .004).ConclusionsThe results indicate a high patient-nurse ratio in adult hospitalization units and that there is a positive association between the patient-nurse ratio and worse results related to nursing care.     

Is complementary and alternative medicine use associated with cancer screening rates for women with functional disabilities?

ObjectivesThe purpose of this study was to examine the associations of complementary and alternative medicine (CAM) use with mammogram and Pap test rates and functional disabilities (FDs).DesignCross-sectional study.SettingData were derived from the 2012 National Health Interview Survey (n = 6576).AnalysisFDs was defined as physical and/or social limitations. The weighted logistic regression models were performed using SAS software. Study covariates were age, race, education, marital status, usual source of care, and insurance.ResultsOf 6576 women, a majority were Caucasian (87%), with GED or less (40%), married (50%), having usual source of care (96%) and health insurance (91%), and with FDs (56%). The results indicated that some CAM practices were negatively associated with increased mammogram and Pap test rates while other CAM practices were positively associated. The results indicated that CAM practices that contribute to musculoskeletal problems such as acupuncture and massage were associated with the increased mammogram and Pap test rates. Contrary, women who used chiropractic manipulation, biofeedback, guided imagery, and energy hearing therapy were less likely to obtain cancer screenings regularly regardless of having FDs.ConclusionsThe use of several CAM therapies was more likely to be associated with mammogram and Pap test frequency, indicating that the CAM use may be associated with better screening rates due to the improvement of musculoskeletal problems. It is important to determine how each CAM therapy improves secondary health conditions in clinical trials to increase cancer screening rates for women with FDs.     

Consulta telemática realizada por Enfermería en pacientes con enfermedad inflamatoria intestinal: valoración de su capacidad resolutiva y costes

IntroductionThe management of patients with inflammatory bowel disease (IBD) is associated with a significant use of healthcare resources. In 2009, a digestive diseases nursing consultation, with availability of health telematic media was created in our hospital (CHUVI).The important activity performed in this area encouraged us to quantify the cost savings for the care health system.Aims1) To evaluate the results of the implementation of a telematic IBD consultation.2) To assess the capacity for resolving problems by nurses.3) To estimate the potential cost savings of telematic nursing consultation in IBD.Material and methodWe collected data on telematic activity from 2009 to 2011.The estimated cost saving was calculated by applying the fees for health services published by our National Health Service (SERGAS) for care in new outbreaks of IBD activity.Data were analyzed with SPSS 15.0ResultsThere was a significant linear increase on the resolution of telephone demands by nurses (P = .03) and an important decrease of demands needing medical advice (P < .0001).Focusing on IBD outbreak claims (n = 452), only 65 patients (14.38%) required medical attention in emergency services, and 33 (7.3%) were hospitalized.Altogether we calculated an average cost saving since 2009 to 2011 of 73,603€.ConclusionsWe found a gradual increase in resolving telematic care demands by nurses.Telematic consultation can lead to significant cost savings, which justify the implementation of a digestive diseases nurse consultation.     

Prospective determination of medical necessity for ambulance transport by paramedics

ObjectiveIt has been estimated that between 11% and 61% of ambulance transports to emergency departments are not medically necessary. This study's objective was to analyze paramedic ability to determine the medical necessity of ambulance transport to the emergency department.MethodsParamedics prospectively assessed adult patients transported to an emergency department during a six-week period. The setting was an urban, all advanced life support, public utility model emergency medical services (EMS) system with 58,000 transports per year. Paramedics determined medical necessity of patient transport based on the following five criteria: 1) need for out-of-hospital intervention; 2) need for expedient transport; 3) potential for self-harm; 4) severe pain; or 5) other. On arrival in the emergency department, the emergency physician made a blinded determination based on the same criteria. Kappa statistics were used to assess agreement.ResultsData forms were completed on 825 of 1,420 (58%) patients transported. Emergency physicians determined 248 (30%) transports were not necessary, paramedics 236 (29%), with agreement in 76.2% (K = 0.42) of cases. Paramedics undertriaged 92 patients (11%). Rates of agreement on the five criteria were: 1) 71.9% (K = 0.43); 2) 77.7% (K = 0.22); 3) 89.6% (K = 0.40); 4) 89.6 (K = 0.32); and 5) 82.2% (K = 0.29).ConclusionsParamedics and emergency physicians agreed that a significant percentage of patients did not require ambulance transport to the emergency department. Despite only moderate agreement regarding which patients needed transport, the undertriage rate was low.     

The effectiveness of the Pain Resource Nurse Program to improve pain management in the hospital setting: A cluster randomized controlled trial

BackgroundThe Pain Resource Nurse program is a widely disseminated, evidence-based, nursing staff development program, designed to improve pain management in hospitals. The program has shown promising results, but has never been tested with a rigorous research design.ObjectivesOur objective was to test the effectiveness of the Pain Resource Nurse program. Hypothesized outcomes included improvements in nurses’ knowledge, attitudes, and assessment practices, and in patients’ participation in decision-making, adequacy of pain management, pain severity, time spent in severe pain, pain interference, and satisfaction.DesignCluster randomized controlled trial.SettingA 650-bed university hospital in IcelandParticipants: The sample consisted of a) patients ≥18 years of age, native speaking, hospitalized for at least 24 h, alert and able to participate; and b) registered nurses who worked on the participating units.MethodsTwenty three surgical and medical inpatient units were randomly assigned to the Pain Resource Nurse program (n = 12) or to wait list control (n = 11). The American Pain Society Outcome Questionnaire and the Knowledge and Attitudes Survey were used to collect data from patients and nurses respectively. Baseline data (T1) for patients were collected simultaneously on all units, followed by data collection from nurses. Then randomization took place, and the Pain Resource Nurse program was instituted. Ten months later, follow up (T2) data were collected, after which the nurses on the control group units received the Pain Resource Nurse program.ResultsAt baseline, data were collected from 305 of the 396 eligible patients and at follow up from 326 of the 392 eligible patients, a 77% and 83% response rate respectively. At baseline, 232 of 479 eligible nurses responded and at follow-up 176 of the eligible 451 nurses responded, a 49% and 39% response rate, respectively. A nested mixed model analysis of covariance revealed that the intervention was successful in changing pain assessment practices, with pain assessment using standardized measures increasing from 13% to 25% in the intervention group while decreasing from 21% to 16% in the control group. None of the other hypothesized improvements were found.ConclusionsThe Pain Resource Nurse program was successful in improving nurses’ use of standardized measures for pain assessment. No effects were found on patient outcomes; pain was both prevalent and severe at both time points. Only minimal improvements were noted in response to this evidence-based staff development program. Changes in pain management practices remain a challenge in clinical settings.     

An evaluation of involving family caregivers in the self-care of heart failure patients on hospital readmission: Randomised controlled trial (the FAMILY study)

BackgroundThe prevalence of heart failure is increasing in Lebanon but to date there is no systematic evaluation of a disease management intervention.ObjectiveThe aim of this study was to evaluate the effect of involving family caregivers in the self-care of patients with heart failure on the risk of hospital readmission.DesignA multi-site, block randomised controlled trial.SettingsThe study was conducted over a 13-month period in three tertiary medical centres in Beirut and Mount Lebanon, Lebanon.ParticipantsAdult patients presenting for an exacerbation of heart failure to one of the study centres were included. Patients with limited life expectancy or physical functionality, planned cardiac bypass or valve replacement surgery, living alone or in nursing homes, or aged less than 18 years were excluded.MethodsPatients allocated to the intervention group and their family caregivers were provided with a comprehensive, culturally appropriate, educational session on self-care maintenance and symptom management along with self-care resources. The usual care group received the self-care resources only. Follow-up phone calls were conducted 30 days following discharge by a research assistant blinded to treatment assignment. The primary outcome was hospital readmission and the secondary outcomes were self-care, quality of life, major vascular events and healthcare utilization.ResultsThe final sample included 256 patients hospitalized for heart failure randomised into control (130 patients) and intervention (126 patients) groups. The mean age was 67 (SD = 8) years, and the majority (55%) were male. Readmission at 30 days was significantly lower in the intervention group compared to the control group (n = 10, 9% vs. n = 20, 19% respectively, OR = 0.40, 95% CI = 0.02, 0.10, p = 0.02). Self-care scores improved in both groups at 30 days, with a significantly larger improvement in the intervention group than the control group in the maintenance and confidence sub-scales, but not in the self-care management sub-scale. No differences were seen in quality of life scores or emergency department presentations between the groups. More patients in the control group than in the intervention group visited health care facilities (n = 24, 23% vs. n = 12, 11% respectively, OR = 0.39, 95% CI = 0.18, 0.83, p = 0.01).ConclusionThe trial results confirmed the potential of the family-centred self-care educational intervention under evaluation to reduce the risk of readmission in Lebanese patients suffering from exacerbated heart failure. Further research is needed to validate these findings with longer periods of follow-up and to identify the intervention components and intensity required to induce sustained benefits on patients' self-care management and quality of life.     

Nurse workload and inexperienced medical staff members are associated with seasonal peaks in severe adverse events in the adult medical intensive care unit: A seven-year prospective study

ObjectiveOur purpose was to identify potential organizational factors that contributed to life-threatening adverse events in adult intensive care unit.MethodsA prospective, observational, dynamic cohort study was carried out from January 2006 to December 2013 in a 20-bed adult medical intensive care unit. All patients admitted to the intensive care unit and who experienced one or more selected life-threatening adverse events (mainly unexpected cardiac arrest, unplanned extubation, reintubation after planned extubation, and readmission within 48 h of intensive care unit discharge) were included in the analysis. Negative binomial regression was used to model how human resources, work organization, and intensive care activity influenced the monthly rate of selected severe adverse events. Data were collected from local and national databases.ResultsOverall, 638 severe adverse events involving 498 patients were recorded. Adverse events increased seasonally in May, November and December (p < .001 vs other months). The proportion of inexperienced nurses and doctors’ working hours could not explain these seasonal peaks of adverse events. Multivariate analysis identified bed-to-nurse ratio and the arrival of inexperienced residents or senior registrars as being independently associated with the rate of adverse events (incidence risk ratio = 1.36 (95% confidence interval, 1.05–1.75), and 1.07 (95% confidence interval, 1.01–1.13), respectively; p = .01 in both cases). According to this model, a one-unit increase in the day–night shifts carried out by each nurse per month tended to reduce the rate of adverse events (incidence risk ratio = 0.60 (95% confidence interval, 0.36–1.01), p = .05). Severity at intensive care unit admission did not influence the rate of adverse events (incidence risk ratio = 1.02 (95% confidence interval, 1.00–1.04), p = .12).ConclusionsResults identify nurse workload and the arrival of inexperienced residents or senior registrars as risk factors for the occurrence of life-threatening adverse events in the adult medical intensive care unit. Limiting fluctuations in bed-to-nurse ratio and providing inexperienced medical staff members with sufficient supervision may decrease severe adverse events in critically ill patients.