Endosurgery: what do we need?

A paradigm shift in therapeutic endoscopy occurred with the advent of mucosectomy for the treatment of mucosal neoplasms and suture plication for gastroesophageal reflux disease. The objectives changed from finding simple, easy, and quick alternatives to surgery to reproducing surgical results. A radical version of flexible endoscopy has emerged to meet new goals of full-thickness resections, creation of anastomoses, and lumen reconfiguration. This will require a new generation of endosurgical tools that cut, stitch, and staple with added dimensions of multiaxis orientation and triangulation.     

Nursing morale: what is it like and why?

BACKGROUND: There has been increased concern in the United Kingdom about the problems of recruitment and retention in the nursing profession, and how this is influenced by low morale. Despite this, however, there are relatively few studies, particularly of a qualitative nature, where nurses are asked about their morale and what factors affect it. AIMS: The present study aimed to explore nursing morale and determine the factors which nurses believed to influence it. By doing so, it was hoped that factors which affect nurse recruitment and retention could be identified. METHODS: Fifty-eight nurses (28 males, 30 females) working in the National Health Service in Scotland were interviewed in depth about their morale and their concerns about their career. Thematic analysis was carried out and a number of main issues emerged. FINDINGS: Morale in this group was very low. A large number of nurses were considering leaving the profession and the majority would discourage others from becoming a nurse. The themes that emerged, which related to their disillusionment, included low pay, lack of support for education, limited opportunity for promotion, lack of resources and job insecurity. CONCLUSIONS: The findings suggest that while recent salary increases may have helped to improve morale, other factors must also be addressed if further decline in morale and a subsequent nursing shortage is to be avoided.     

Nursing handovers: do we really need them?

AIM: This study attempts to address the content of nursing handover when compared with formal documentation sources. BACKGROUND: The nursing handover has attracted criticism in the literature in relation to its continuing role in modern nursing. Criticisms include those related to time expenditure, content, accuracy and the derogatory terms in which patients are sometimes being discussed. METHODS: Twenty-three handovers, covering all shifts, from one general medical ward were audio-taped. Their content was analysed and classified according to where, within a ward's documentation systems, the information conveyed could be located. FINDINGS: Results showed that almost 84.6% of information discussed could be located within existing ward documentation structures and 9.5% of information discussed was not relevant to ongoing patient care. Only 5.9% of handover content involved discussions related to ongoing care or ward management issues that could not be recorded in an existing documentation source. LIMITATIONS: The results of this study are representative of only one ward in one Australian Hospital. Specific documentation sources were also not checked to determine their content. CONCLUSION: Streamlining the nursing handover may improve the quality of the information presented and reduce the amount of time spent in handover.     

Fluoroquinolone-induced tendinopathy: what do we know?

Fluoroquinolones are relatively safe, effective antibiotics. As their use becomes more frequent, so will the adverse side effects. I highlight a rare but debilitating adverse reaction-fluoroquinolone-induced tendinopathy. Case reports and letters from 1987 to 1998 were identified by using Grateful Med and PubMed Internet accesses to the National Library of Medicine. Articles were reviewed for clinical practicality. There are few articles on fluoroquinolone-induced tendinopathy in the US literature targeting primary care physicians. This entity has been described in many case reports, but little has been done to isolate the causative agents. Incidence of this side effect is difficult to estimate, since no prospective studies are available for review or calculation of risk. Fluoroquinolone-induced tendinopathy appears more commonly in tendons under high stress. The cause is probably multifactorial. Risk factors for the development of fluoroquinolone-induced tendinopathy are age, renal failure, corticosteroid use, and previous tendinopathy from fluoroquinolones.     

Blood transfusion in burns: what do we do?

Over 11 million units of blood are transfused yearly in the United States. Although blood transfusion is common in burns, data are lacking on appropriate transfusion thresholds. The purpose of the study was to identify current burn center physician blood transfusion practices. A 30-question survey of blood transfusion practices was developed and sent to burn center directors. The survey assessed demographics, burn experience, and blood transfusion thresholds. Physicians were asked to list factors affecting their blood transfusion thresholds and then to give their blood transfusion threshold for patients based on age and percent burn. The final section presents three case scenarios with alterations in one physiological parameter to assess the effect on transfusion thresholds. A total of 55 of the 180 surveys (31%) were returned. Mean number of burn beds was 15.7 +/- 1.4, with 264 +/- 25 burn admissions per year. The respondents had been in burn care for 15.9 +/- 1.4 years. Their mean hemoglobin transfusion threshold was 8.12 +/- 1.7 g/dl. The most frequent reasons for transfusion were ongoing blood loss (22%), anemia (20%), hypoxia (13%), and cardiac disease (12%). Inhalation injury influenced the decision to transfuse blood in 34%. The hemoglobin level below which respondents would transfuse blood increased with increasing TBSA burn, history of cardiac disease, acute respiratory distress syndrome, and age. Blood transfusion thresholds in burns vary based on burn percentage, age, and presence of cardiac disease. To date, no standard of care exists for blood transfusions in burns. Future prospective studies are needed to determine the appropriate use of blood in burns.     

Early goal-directed therapy: what do we do now?

The meta-analysis of early goal-directed therapy (EGDT) by Gu and colleagues in the previous issue of Critical Care adds to the ongoing controversy about the value of EGDT for resuscitating patients with severe sepsis and septic shock. The results of the ProCESS (protocolized care for early septic shock) and ARISE (Australasian resuscitation in sepsis evaluation) trials failed to demonstrate any benefit of EGDT or protocolized resuscitation when compared with ‘usual care’. The questions are the following: What is ‘usual’ care? What is ‘real world’ care? Do the results of a robust and well-conducted randomized controlled trial - in which many patients may be excluded for a variety of reasons - reflect the care given to patients on a daily basis in our emergency departments and intensive care units? Of course, there are no obvious answers to these questions, and many clinicians look forward to managing these patients without protocols. For now, the data do seem to support the management of patients with septic shock without mandated central lines or protocols. Does this mean we should go back to the era of ‘do whatever you want’? No consensus exists among clinicians regarding optimal hemodynamic monitoring, and to date no method has been proven to be superior. Given the amount of fluids given prior to randomization in the ProCESS and ARISE trials, ‘usual care’ appears to now include aggressive, early fluid resuscitation with at least 20 mL/kg of crystalloid and rapid administration of appropriate antibiotics. Certainly, this reflects the impact of the original trial by Rivers and colleagues and the broad-based implementation of the Surviving Sepsis Campaign Guidelines and bundles. If this continues to define ‘usual care’, then perhaps it is no longer necessary to mandate specific protocols for resuscitation, as it appears that standard sepsis management has evolved to be consistent with published protocols.     

Error reporting in the emergency department: do we do what we say we do?

BACKGROUND:

The Joint Commission accreditation manual contains standards in improving organization performance related to report and review of patient care issues causing unexpected harm. In spite of regulations mandating reporting, it remains inconsistent, varying by provider type and hospital. Our purpose was to determine current attitudes, knowledge, and practice of error reporting among emergency department (ED) providers.

METHODS:

We administered a survey assessing ED staff practice regarding error reporting. Questions involved reporting of errors in which the practitioner was directly involved, errors the practitioner observed, and general awareness of reporting mandates. We also questioned individuals regarding fear of repercussions for reporting.

RESULTS:

Fifty-two surveys were returned. For most errors, providers were more likely to tell their supervisor about the issue than to tell the patient. Seventeen percent of respondents did not think that referring errors for review was their job. Only 31% of respondents were aware of standardized institution-wide pathways to report errors. Any respondent who was aware of the institution-wide pathway also felt responsibility for error reporting. Thirty-three percent of the respondents were concerned about negative repercussions from reporting errors. In querying the hospital reporting system, 263 cases were referred for quality issues over the previous year, 51% of them were referred by nurses, 27% by medical technicians (MTs), 2% by mid-level providers (MLPs), 1% by physicians, and 19% by other personnel.

CONCLUSION:

Although most of the ED staff are responsible for patient safety, most are not aware of systems available to assist in reporting, and even many do not utilize those systems.KEY WORDS: Error reporting, Quality assurance, Medical error     

International haemovigilance: what have we learned and what do we need to do next?

The International Haemovigilance Network (IHN) defines haemovigilance as ‘a set of surveillance procedures covering the whole transfusion chain (from the collection of blood and its components to the follow‐up of recipients), intended to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products, and to prevent their occurrence or recurrence’. IHN, the International Society of Blood Transfusion and World Health Organization work together to support both developing and established haemovigilance systems. Haemovigilance systems provide valuable data on a range of adverse events related to blood donation and clinical transfusion, from donor syncopal events to transfusion‐transmitted infections, immunological complications and the impact of human errors. Harmonised definitions for most adverse reactions have been developed and validated internationally. Definitions of pulmonary complications are again under review. Haemovigilance data have resulted in changes in policy, products and practice, and can complement and inform clinical audit and research, leading to improved blood donor safety, optimised product use and better clinical outcomes after transfusion. However, more work is needed. Not all countries have haemovigilance systems in place. More robust data and careful analysis are required to improve the understanding of the causes, occurrence and clinical outcomes of these events. Wider dissemination of results will facilitate health policy development internationally, and implementation of haemovigilance recommendations will support further important progress in blood safety.     

Nursing and the aging workforce: myths and reality, what do we really know?

Not unlike the general population, the population of nurses is aging. This trend is problematic for the nursing workforce in the light of a predicted shortage yet the extent of the effect of the aging population is unknown. What should individuals older than 45 years know to mitigate the effects of aging both physically and professionally? This article describes the magnitude of the aging nursing workforce issue, explores the myths and realities related to the aging process, discusses evidence-based strategies supporting healthy aging and retention of experienced nurses in one Magnet hospital, and introduces recommendations for further study.