The legal danger of written protocols and standards of practice.

Nurse practitioners have historically developed protocols and standards of practice to guide and improve the quality of their patient care. Written protocols and standards of practice can, however, create a potential malpractice problem. Lawyers who bring malpractice cases on behalf of patients will use the protocols and standards to measure the practitioner's care. The practice standards are often too high to be reasonably met by practitioners at all times and in all settings. As a result, the practitioner's care may breach those standards. Nurse practitioners should develop protocols that are based on a minimum safe level and not the maximum level aimed at ideal care. Standards and protocols should be updated and realistic. Once developed, protocols and standards must be followed precisely to limit potential liability.     

Sentinel lymph nodes in cutaneous melanoma

Examination of sentinel lymph nodes (SLN) has probably become the most popular method of early staging of patients who have cutaneous melanoma because SLN are considered to be the lymph nodes most likely to contain metastatic deposits; they can be examined in a more intense manner than in standard lymphadenectomy. There are several protocols to examine SLN but most of them use formalin-fixed, paraffin-embedded sections stained with hematoxylin and eosin with the addition of immunohistochemistry. By using these protocols, approximately 20% of patients who have cutaneous melanoma have melanoma cells in the SLN. Current studies are evaluating the possible therapeutic value of removal of positive SLN, but it is accepted by most authors that detection of positive SLN conveys an impaired prognosis for patients who have cutaneous melanoma.     

Quantitative assessment of neuropathic pain

Quantitative sensory testing (QST) refers to a group of protocols that allows for quantitative measures of somesthetic function. Several protocols evaluate perceptual threshold, whereas others evaluate perception of stimuli above threshold. Each protocol has its own advantages and disadvantages, but one must always weigh a trade-off between accuracy (with longer protocols) and expediency (with shorter protocols). In assessing patients with neuropathic pain, one is interested in both positive and negative sensory symptoms. QST studies, using either neuropathic pain patients or healthy volunteers who have been rendered temporarily hyperalgesic, have demonstrated that pain abnormalities can be modality specific. The fact that various pain abnormalities can exist independently of each other suggests that (at least partially) different neuropathologic processes are responsible for each one. Current research suggests that both peripheral sensitization and central sensitization play a role in these abnormal pain conditions, and identification of precise neuropathologic mechanisms is under active investigation.     

Chemotherapy in adult cancer. When is it most useful?

Much has been accomplished in the cure of cancer with chemotherapy, but much remains to be done. The primary care physician's responsibility is to know which cancers are curable and in which a significant portion of patients may benefit from chemotherapy. Patients with a malignancy in a relatively resistant organ site represent the greatest challenge to the "art" of medicine. Even if more than half of patients with a given malignancy are cured by chemotherapy, the remainder deserve the right to participate in research protocols, an undertaking that might further improve these otherwise substantial gains. As research studies show improved cure rates with antineoplastic agents, the need to reduce both short- and long-term side effects will remain a challenge.     

Commonly used chemotherapeutic agents

The primary care physician is often responsible for the management of cancer patients who may be receiving complex chemotherapeutic regimens. The World Health Organization has recommended standard approaches to recording baseline data and reporting treatment results (see Table 4, pp 252-253). These standards are intended for international use to compare results from various centers or investigators. Most antineoplastic agents have a number of serious toxicities or adverse effects associated with their use. By recognizing and quickly diagnosing drug-induced adverse effects of antineoplastic agents, morbidity or early mortality may be avoided.     

Intraarterial cisplatin infusion: nursing implications

Patients diagnosed with malignant intracranial tumors have limited chemotherapeutic options. Recent studies have shown that intraarterial infusions of antineoplastic agents to regionally confined malignancies may be of great benefit. Clinical trials of intraarterial infusions of the drug cisplatin are investigating its efficacy in treating intracerebral gliomas. This paper presents the rationale for such treatment and emphasizes nursing responsibilities relative to the treatment protocols.     

Maximizing benefits and minimizing risks in palliative care research that involves patients near the end of life

Research in end-of-life care is constrained more by pragmatic, social, cultural, and financial constraints than ethical issues that preclude the application of typical research methodologies. When normally accepted and ethically sound protections for subjects (especially for those who lack independent decision-making) are in place, exclusion of patients with far advanced disease from research is in and of itself unethical. Involvement in research may have a therapeutic, anticomiogenic effect on dying patients and their families. Institutional review boards must be educated to evaluate research protocols involving this group of vulnerable patients with an eye toward assuring that ethical safeguards are in place, conflicts of interest are transparent and minimized, and that the proposed methodology has duly considered all practical exigencies so that resources and peoples' time and emotional investments are not squandered. Investigators and research review committees must be knowledgeable about placebo effects and under what types of circumstances their use is justifiable, preferred or requisite to fulfill both ethical and scientific imperatives. Examples of investigations using various research methodologies, along with their respective ethical considerations are provided.     

An unusual cause of chest pain in a 33 year old male: neurofibromatosis

Chest pain in low risk patients is a common ED presentation. Rarely, these patients can have life-threatening conditions requiring timely diagnosis and intervention. There are currently standardized protocols for diagnosing cardiac ischemia, pulmonary embolus, and aortic dissection in low risk patients. Even more rare entities such as esophageal perforation, hemo/pneumothorax, and cardiac tamponade must also be kept in mind. We present the case of chest pain in a 33 year old male reporting no significant past medical history who developed spontaneous massive hemothorax while being evaluated in the ED. Subsequent investigation revealed that the patient had neurofibromatosis; the etiology of aneurysmal rupture in neurofibromatosis is discussed.     

Mucocutaneous herpetic infections during cancer chemotherapy

Adults who are given immunosuppressive and myelosuppressive cancer chemotherapy have a heightened risk for development of herpetic infections during treatment. The impact is much greater in patients who are given antineoplastic drugs for leukemia and lymphoma than in those who are given such drugs for carcinoma and sarcoma. In the series reported here, the incidence of herpes simplex infections exceeded that of herpes zoster infections in patients treated for leukemia by a ratio of more than 12:1, compared to slightly more than 2:1 in patients treated for solid tumor. The frequency of herpes simplex and herpes zoster infections during treatment for leukemia was 25%. Corresponding frequencies for patients with lymphoma, carcinoma, and sarcoma were 28%, 8%, and 3%, respectively.     

Potential applications of therapeutic drug monitoring in treatment of neoplastic disease by antineoplastic agents

Therapeutic drug monitoring of antineoplastic agents must be considered in terms of cytotoxicity to stem cells and toxicity of normal tissues. The dose-limiting toxicity which is myelosuppression is believed to be a necessary effect for maximal antitumour effect. The areas in which therapeutic drug monitoring can play a role include: predicting patients at risk of toxicity, e.g. high dose methotrexate therapy; low bioavailability, e.g. oral 6-mercaptopurine; identifying patients at risk of treatment failure, e.g. methotrexate clearance in acute lymphoblastic leukemia. Although therapeutic drug monitoring is not clinically useful at present, the potential role it can play is illustrated for cytosine arabinoside, adriamycin and cyclophosphamide. Two problems encountered with drug monitoring of antineoplastic disease are tumour heterogeneity manifested by clonal, nutritional and physical characteristics and the common practice of combination chemotherapy. These problems must be addressed in order to make therapeutic drug monitoring a practical tool in cancer chemotherapy. Future applications of therapeutic drug monitoring will require more studies to define therapeutic ranges for single agents, patient-to-patient variation, course-to-course variation and the effects of drug combinations on pharmacokinetic profiles of the drugs used.     

Nononcologic use of chemotherapy.

Autoimmune disorders currently number more than 80 and have the potential for rising higher. Intravenous chemotherapy drugs, including antineoplastic and biologic agents, have long been associated with the treatment of malignant diseases. Because intravenous "chemotherapy" drugs are also included as treatment options for these disorders, more nononcology nurses are expected to possess the knowledge and skill to administer and manage these therapies. Issues such as drug knowledge, safe handling, disposal, side effect management, and patient education must be a part of the administering nurse's education and competency.     

Making weaning easier. Pathways and protocols that work

Clinical pathways and weaning protocols are useful tools for improving the care of patients requiring LTMV. The value of the pathways and protocols rests in large part on the systematic multidisciplinary nature of the tools. Nevertheless, for the pathways and protocols to truly affect outcomes, they must be carefully designed. It is critical that this occurs with the input of experts, and especially in the case of pathways, a seasoned knowledgeable clinician should guide the process. The success of such care delivery models rests with the quality of those who design, test, and revise them. If developed in a careful and thoughtful manner using the best science available, the pathways and protocols may truly be powerful tools for clinical practice.     

Strategies to optimize analgesia and sedation

Achieving adequate but not excessive sedation in critically ill, mechanically ventilated patients is a complex process. Analgesics and sedatives employed in this context are extremely potent, and drug requirements and metabolism are unpredictable. Clinicians must have heightened awareness of the potential for enduring effects and are encouraged to employ strategies that maximize benefit while minimizing risk. Successful sedation protocols have three basic components: frequent assessments for pain, anxiety, and agitation using a reproducible scale; combination therapy coupling opioids and sedatives; and, most importantly, careful communication between team members, with a particular recognition that the bedside nurse must be empowered to pair assessments with drug manipulation. In recent years, two broad categories of sedation protocols have achieved clinical success in terms of decreasing duration of mechanical ventilation and intensive care unit length of stay by minimizing drug accumulation. Patient-targeted sedation protocols (the first category) rely on structured assessments to guide a careful schema of titrated drug escalation and withdrawal. Variation exists in the assessment tool utilized, but the optimal goal in all strategies is a patient who is awake and can be readily examined. Alternatively, daily interruption of continuous sedative infusions (the second category) may be employed to focus care providers on the goal of achieving a period of awakening in the earliest phases of critical illness possible. Newer literature has focused on the safety of this strategy and its comparison with intermittent drug administration. Ongoing investigations are evaluating the broad applicability of these types of protocols, and currently one may only speculate on whether one strategy is superior to another.     

Assessing workplace compliance with handling of antineoplastic agents

Oncology nurses and ancillary support personnel who work in oncology settings are at risk for exposure to antineoplastic drugs in their workplaces. A review of the literature reveals issues of environmental contamination and personal exposure. Although the United States has no formal regulations regarding hazardous drugs, including cytotoxic agents, guidelines have been published and are readily available to improve workplace safety. Oncology healthcare workers must be aware of the serious nature of antineoplastic drug exposure and the avenues available to initiate a simple, highly effective, problem-solving process called SOLVE to make medical workplaces safer.     

Brain resuscitation. Ethical perspectives

Brain resuscitation is the newest in a long line of treatment protocols that is designed to aid us in sustaining not just life, but quality life in the critical care setting. Like other, previously established protocols, it is not value free. Its implementation brings ethical considerations that must be addressed. If the issues are not addressed, there is the real danger that the resulting moral dilemmas will overwhelm the nurse. In brain resuscitation, there are at least three ethical issues that must be recognized. These are the role of resuscitation in the life process, allocation of scarce resources, and participation in research. To address these issues, nurses will have to be aware of the ethical principle and/or perspectives involved. For some of these issues, the solutions will have to come from nursing's national organizations, such as the American Association of Critical Care Nurses. Other solutions presented will require the nurse to come to an individual decision regarding the ethics of brain resuscitation. The journey to the conclusion of this discussion will end with disappointment for those who sought an algorhythm or decision tree with which to make definitive decisions in regard to ethical decisions about brain resuscitation. To have assumed that such an absolute discussion in regard to the ethical perspectives related to brain resuscitation is possible or even desirable would have been to deny the moral/ethical responsibilities of the nurse who practices in a critical care setting. While these ethical responsibilities can be overwhelmingly burdensome, they can also be opportunities. They can be positive opportunities for our health care colleagues, our patients, and ourselves.     

Herpes simplex virus and oral mucositis in children with cancer

The relationship between herpes simplex virus (HSV) and oral mucositis was investigated in children undergoing antineoplastic chemotherapy. HSV culture was performed in 20 children with stomatitis developing after antineoplastic chemotherapy. Viral isolates were typed and susceptibility to acyclovir was investigated. The virus was isolated from oral lesions in 10 of 20 children with severe oral mucositis. Viral reactivation was the most likely explanation in most cases, since HSV was isolated in 9 of 13 seropositive patients (and in 1 patient with unknown anti-HSV serology), but in no seronegative patient. HSV type 1 was isolated more frequently than HSV type 2 (8 versus 2). Acyclovir showed standard in vitro activity against all isolates. Our results suggest that oral mucositis in children receiving antineoplastic treatment is probably multifactorial in origin and that HSV can be an important cofactor, especially in children who are seropositive for HSV. In our Centre, acyclovir remains active in vitro against this opportunistic pathogen and could be employed in prophylaxis and therapy.     

Pills, panics, precautions

This article discusses on the increasing role of nurses in contraceptive services and their need for updated information to respond to product changes and media scares. The role of nurses in providing contraception services will grow more heavily especially given delivery of medicines through group protocols and the prospect of an expansion in nurse prescribing. Moreover, nurses are confronted with the issues of limited contraceptive choices, media scares especially on pill risks, the need to make emergency contraception accessible and the declining teenage contraception. They have to be well trained and must keep abreast of research in order to convey all of the risks of contraceptives without alarming people. Some nurses have been working to good protocols, on trust, for issuing emergency contraception to women over age 16, and some under that age. In dealing with young people who are alienated and intimidated by mainstream family planning services, health boards have considered services especially designed for young people.     

Drug–drug interactions in HIV positive cancer patients

Clinically relevant drug–drug interactions (DDIs) refer to the pharmacological or clinical response to the administration or co-exposure of a drug with another drug that modifies the patient's response. Treatment regimens, which include agents that are involved in the cytochrome P450 (CYP450) enzyme system and transporter systems, such as P-glycoprotein may be associated with higher risk of clinically significant drug interactions. In addition, potential DDIs increase with the increasing number of concomitant drugs. HIV positive cancer patients who receive concomitant chemotherapy and combination antiretroviral therapy (cART) may achieve better response rates and higher rates of survival than those who receive chemotherapy alone, but they may be at increased risk of drug interactions. DDIs in HIV positive cancer patients receiving concomitant chemotherapy and cART may increase or decrease antineoplastic drug concentrations, potentially resulting in life threatening interactions, increased toxicity or loss of efficacy. Avoiding and managing potential interactions between cART and antineoplastic agents is an increasingly important challenge. Based on the current literature, more safety and pharmacokinetic studies are needed with the aim to document a clear survival benefit for patients undergoing chemotherapy and concomitant or sequential administration of cART.     

Triage decisions for ICU admission: Report from the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine

Demand for intensive care unit (ICU) resources often exceeds supply, and shortages of ICU beds and staff are likely to persist. Triage requires careful weighing of the benefits and risks involved in ICU admission while striving to guarantee fair distribution of available resources. We must ensure that the patients who occupy ICU beds are those most likely to benefit from the ICU's specialized technology and professionals. Although prognosticating is not an exact science, preference should be given to patients who are more likely to survive if admitted to the ICU but unlikely to survive or likely to have more significant morbidity if not admitted. To provide general guidance for intensivists in ICU triage decisions, a task force of the World Federation of Societies of Intensive and Critical Care Medicine addressed 4 basic questions regarding this process. The team made recommendations and concluded that triage should be led by intensivists considering input from nurses, emergency medicine professionals, hospitalists, surgeons, and allied professionals. Triage algorithms and protocols can be useful but can never supplant the role of skilled intensivists basing their decisions on input from multidisciplinary teams. Infrastructures need to be organized efficiently both within individual hospitals and at the regional level. When resources are critically limited, patients may be refused ICU admission if others may benefit more on the basis of the principle of distributive justice.     

RCPs (respiratory care practitioners) and health-care reform: demonstrating value, creating opportunity

We should embrace respiratory care protocols. We have had a system in our hospital for more than two years; it has been very successful. We have approximately 60-70% of all of our therapy now ordered by a true protocol process. Some people have been dragged kicking and screaming through this process, including a number of respiratory care practitioners. It is more work. It is harder. Yes, it takes more time and more work to be a professional, but a professional is what you want to be. Anybody can go around and stick those nebulizers in people's mouths, but not everyone has the skill to determine which patients do not need that nebulizer or which may need a different drug or a different therapy. We must demonstrate through projects our ability to have an impact on the delivery of unnecessary and inappropriate care, and we must have physician support for what we are doing. These elements are essential to our survival. When we embrace appropriate and effective technology, we demonstrate value. If we show--through improved weaning technology--that we can decrease length of stay by decreasing the time that people are on ventilators, we demonstrate value. If we function as effective bronchoscopy assistants who help to treat people and get them out of the hospital or avoid hospitalization entirely, we demonstrate value. So, we must embrace technology. We need to function across the entire continuum of care to demonstrate value. We need to start managing health instead of managing illness.(ABSTRACT TRUNCATED AT 250 WORDS)