Standards of care: are they being used?

Electronic access to standards of care is viewed as a promising strategy for increasing evidence-based practice. Before determining whether electronic access to standards will increase nurses' use of standards of care, data on their current rate of utilization are needed. Using 2 standards of care, Fluid Volume Excess and Manic Behavior, we used retrospective chart reviews to gather baseline information. Insights from these findings are presented.     

Intensive care course after stage 1 Norwood procedure: are there early predictors of failure?

Objective The purpose of this study was to review the early postoperative course of stage 1 Norwood with Blalock-Taussig shunt (BTS) or right ventricle-to-pulmonary artery conduit (RVPA) and to identify early predictors of failure. Material and methods A retrospective analysis was conducted in 33 consecutive neonates who underwent BTS (n = 19) or RVPA (n = 14) stage 1 Norwood procedure between 2000 and 2005. Pre-, peri-, and postoperative data included: hourly hemodynamics and blood gases, pulmonary to systemic flow ratio, duration of mechanical ventilatory and inotrope support, intensive care and hospital stay. Failure was defined as death or transplantation. Results Thirteen patients failed the procedure (39.4%): 10 BTS (52.6%) and 3 RVPA (21.4%). Failure decreased from 61.1% in 2000–2002 to 13.3% in 2003–2005 and was associated with: low systolic, mean and diastolic blood pressure, urine output, pH, base excess, bicarbonates, and high pulmonary to systemic flow ratio within 24 h postoperatively. Arterial oxygen and CO₂ pressure, and oxygen saturation did not differ with failure. RVPA had higher diastolic blood pressure and more stable hemodynamics despite similar pulmonary to systemic flow ratio. Duration of mechanical ventilation, inotrope support, intensive care stay were shorter in RVPA. Postoperative echographic ventricular dysfunction and tricuspid regurgitation grade were correlated with failure. Conclusions Excessive pulmonary to systemic flow ratio and low blood pressure are associated with failure. High diastolic blood pressure more than low pulmonary to systemic flow ratio seems to account for more favorable outcomes in RVPA compared to BTS procedure.     

The nurse practitioner in primary care: alleviating problems of access?

Improving access to primary care services is an essential component of the NHS modernization plan and the advent of independent nurse practitioners in primary care has focused attention on the extent to which this group of nurses can effectively substitute for GPs. This study was designed to explore the role of a nurse practitioner in primary care, particularly whether the provision of a nurse practitioner facilitated access to care that met the needs of patients. Semistructured interviews were conducted with 14 patients who had consulted with the nurse practitioner, 10 staff within the practice who had knowledge of the role, and the nurse practitioner herself. With the permission of interviewees, interviews were audiotaped, the tapes transcribed verbatim, and the data were coded by theme. It was perceived by both groups of interviewees that access to care had been improved in that there were more appointments available, appointments were longer than they had been previously and were available at different times of the day. However, some areas in which access was 'restricted' were articulated by staff interviewees, such as limitations to the nurse practitioner's prescribing and problems with referring patients to secondary care. Additionally, while access to a member of the primary healthcare team was improved for many patients, access to a specific member of the team, such as a GP, was not always improved. Concerns were also expressed about how the role of the nurse practitioner needed to be developed in the practice. It can be concluded from this study that, potentially, the role of nurse practitioner has much to offer in terms of addressing problems of access in primary care for some patients. However, this is not a straightforward solution and in order for the role to be effective several issues highlighted in this study require addressing.     

Migraine care among different ethnicities: do disparities exist?

OBJECTIVE: Evaluate whether, in a primary care setting, Caucasians (C) and African Americans (AA) with moderately to severely disabling migraines differed in regards to: utilizing the health-care system for migraine care, migraine diagnosis and treatment, level of mistrust in the health-care system, perceived communication with their physician, and perceived migraine triggers. BACKGROUND: Research has documented ethnic disparities in pain management. However, almost no research has been published concerning potential disparities in utilization, diagnosis, and/or treatment of migraine. It is also important to consider whether ethnic differences exist for trust and communication between patients and physicians, as these are essential when diagnosing and treating migraine. METHODS: Adult patients with headache (n = 313) were recruited from primary care waiting rooms. Of these, 131 (AA = 77; C = 54) had migraine, moderate to severe headache-related disability, and provided socioeconomic status (SES) data. Participants completed measures of migraine disability (MIDAS), migraine health-care utilization, diagnosis and treatment history, mistrust of the medical community, patient-physician communication (PPC), and migraine triggers. Analysis of covariance (controlling for SES and recruitment site), chi-square, and Pearson product moment correlations were conducted. RESULTS: African Americans were less likely to utilize the health-care setting for migraine treatment (AA = 46% vs. C = 72%, P < .001), to have been given a headache diagnosis (AA = 47% vs. C = 70%, P < .001), and to have been prescribed acute migraine medication (AA = 14% vs. C = 37%, P < .001). Migraine diagnosis was low for both groups, and <15% of all participants had been prescribed a migraine-specific medication or a migraine preventive medication despite suffering moderate to severe levels of migraine disability. African Americans had less trust in the medical community (P < .001, eta2 = 0.26) and less positive PPC (P < .001, eta2 = 0.11). Also, the lower the trust and communication, the less likely they were to have ever seen (or currently be seeing) a doctor for migraine care or to have been prescribed medication. CONCLUSIONS: Migraine utilization, diagnosis, and treatment were low for both groups. However, this was especially true for African Americans, who also reported lower levels of trust and communication with doctors relative to Caucasians. The findings highlight the need for improved physician and patient education about migraine diagnosis and treatment, the importance of cultural variation in pain presentation, and the importance of communication when diagnosing and treating migraine.     

The impact of critical care outreach: is there one?

An evaluation of critical care outreach services was published in the previous issue of Critical Care that fails to demonstrate any important outcome benefit associated with these services. It is now time to ask some difficult questions about the future of outreach, including whether the lack of evidence should lead to disinvest-ment in such services.     

The shortage of critical care physicians: Is there a solution?

Objective

The objective of this study is to provide a solution to the critical care physician shortage.

Data sources

The data sources are Medline search of published articles regarding the critical care physician shortage, the current training model, and the roll of family physicians.

Data extraction

The US population continues to age, increasing the need for critical care services due to the burden of acute and chronic illnesses. At the same time, it has been suggested that a highly staffed intensive care unit (ICU) including physicians, nurses, and pharmacists promotes standardized care that improves survival and length of stays (hospital and ICU). This has led to a rise in critical care physician staffing.Unfortunately, estimates indicate a shortage of critical care physicians over the next 10 years or even sooner if the Leapfrog initiative is implemented, making apparent the vulnerability of the field. Published estimates indicate that intensivists currently provide care to only 37% of all ICU patients in the United States and that they are located primarily in large hospitals and teaching institutions.Traditionally, to enter a fellowship in critical care, one would have to be trained through the internal medicine, anesthesia, or surgery pathways. Recently, the American Board of Emergency Medicine, in conjunction with The American Board of Internal Medicine, opened the pathway for emergency physicians to enter a critical care fellowship.

Conclusions

Family Practice is the second largest collective group of physicians in the United States—second only to internal medicine. In most of rural America, where there are limited physicians serving the population, family practitioners fill the gap and provide services otherwise unavailable to those patients. This group that can potentially be trained in critical care and help solve the crisis has been prevented from doing so.     

Can state medical boards adequately respond to reports that physicians are inappropriately prescribing opioids?

In this issue, Reidenberg and Willis share results of a 2-year study of cases in which physicians were criminally prosecuted for their prescribing of opioids "outside the bounds of proper medical practice."(1) They found that in only two of 32 such cases had a state medical board reviewed the case before indictment. In many of the cases, the authors argue that the prosecutors overreached and that these kinds of cases could be better handled by referral to state medical boards.