Can the use of LPNs alleviate the nursing shortage? Yes, the authors say, but the issues--involving recruitment, education, and scope of practice--are complex

OVERVIEW: LPNs may be able to help fill some of the gaps caused by the nursing shortage, but little research has been conducted on the demographic characteristics of LPNs, their education and scope of practice, and the demand for their services, all of which vary from state to state. In 2002 and 2003, the authors conducted a comprehensive national study, Supply, Demand, and Use of Licensed Practical Nurses, and have summarized that study's findings in this article. They found that RNs and LPNs are similar in age and tend to have similar numbers of children, but that racial and ethnic minorities, particularly African Americans, and those who are single, widowed, divorced, or separated are better represented among LPNs. Expanding LPN educational programs might draw more people into nursing. Some LPNs would like to become RNs, so expanding LPN-to-RN "ladder" programs could also be beneficial. LPNs can't replace RNs entirely, but they could perform much of the work now performed by RNs. While long-term care facilities already depend heavily on LPNs, hospitals could benefit from employing more LPNs. The authors make several specific policy recommendations to improve the education and employment of LPNs.     

Through which layer,between the gallbladder and the liver,does the deep branch of the cystic artery run?

Introduction: During laparoscopic cholecystectomy, an enlarged field of vision increases safety and precision, but surgeons often encounter bleeding that can cause difficulties. It is important to prevent and control arterial bleeding from Calot's triangle and the liver bed that results from injury to the deep branch of the cystic artery (DBCA). However, no previous reports have mentioned the layer between the gallbladder and liver through which the DBCA runs. Materials and Surgical Technique: To determine this layer, we investigated the histological findings from consecutive thin‐slice (3 mm) blocks in six cases (three cadavers and three patients who underwent extended cholecystectomy). Results: The subserosal layer of the gallbladder wall can be divided into an inner (ss‐i) layer, which consists of abundant vasculature and some fibrous tissue, and an outer (ss‐o) layer, which consists of abundant fat tissue. DBCA runs through the ss‐o layer, far from the ss‐i layer in Calot's triangle, and runs toward the gallbladder body and ramifies into several branches that flow into the ss‐i layer. Discussion: If the gallbladder is dissected in the layer close to the ss‐i layer, as in our standardized procedure, the subbranches of DBCA are transected at the border of the ss‐i layer, and most of the DBCA is left within the ss‐o layer in Calot's triangle and the liver bed. Knowledge of the anatomy of DBCA is useful to avoid and stop bleeding from the deep part of Calot's triangle and the liver bed.     

Poison center surveillance data: the good,the bad and … the flu

Background.?Poison center data are increasingly used by state health departments and the Centers for Disease Control and Prevention for public health surveillance. Forrester and colleagues evaluated the ability of 6 Texas poison centers covering a population of 24 million to accurately code and report the number of H1N1 calls received over a 5-month period.?Discussion.?The Texas poison centers generated new coding and began work within 24 h of notification of the surveillance need. No additional staff were added for call management, coding, or quality assurance, and no H1N1 training was provided ahead of time. A triple-redundancy coding method was used to prevent underreporting of calls. This allowed the Texas poison centers to accurately flag over 90% of H1N1 cases. Results were available in real time, allowing day-to-day monitoring by poison centers and the state public health department for surges, location, ages of callers and/or patients, and type of question.?Conclusion.?The accuracy of poison center near real-time toxicosurveillance data coding was sufficient to monitor emerging trends. The data generated by poison centers are flexible, immediate, unique from other data sources, and useful for trend monitoring. As health departments and other collaborative partners rely more on the data from poison centers, consideration must be given to appropriate funding to support coding training, monitoring, and quality assurance to further enhance this valuable system.

This commentary should have been published alongside the following article: Coding of influenza A H1N1 virus calls received by Texaspoison centers Mathias B. Forrester and Jeanie E. Jaramillo Clinical Toxicology, Vol. 48, No. 4: 359–364.     

In the hospital setting, what is the patient's role?

It is crucial for all medical institutions to maximize the selection of their actors in strict accordance to equality. As medical administrators, were are questioned on the problems linked with compartmentalization. Our investigation has allowed us to confirm that the ensemble of actors, including the patient, regulates compartmentalization, and that all in all it works rather well. However, this regulation has a price. It has an impact on organization, the energy used, not to mention the cumbersome side-effects that would be felt. We have chosen to focus our research on the patient's role on regulation by using his/her testimony. The patient is never passive. Adaptation requires real efforts on the patient's part in order to adapt to this new environment, while at the same time economizing his/her strength. The regulation carried out is often standardized. The patient conforms, but against his/her will. Does the patient's admittance to the hospital make him/her a second-class citizen? Our results lead us to believe that the prevailing views advocate that the patient be at the heart of the system remain an objective.     

Culture, ethnicity, race: what's the difference?

Culture can be seen as a dynamic, ever-changing process. When caring for children and families from diverse backgrounds nurses need to be able to accomodate differences willingly and competently. Do not be afraid to ask--you cannot know everything about someone else's culture. Every unit/team should have contact details of advocates, translators, and local leaders whose support the family may desire, and have information available in other languages which explain the terminology used by healthcare professionals. Nurses can show respect by being available and accessible and by not imposing their own beliefs or agendas.     

Traumatic cardiac arrests - the action or the provider,what makes the difference?

Traumatic cardiac arrest resuscitation is considered a heroic and futile endeavor. However, newer articles have more promising statistics and divide between prehospital ground and helicopter transport. Here we discuss why there might be a difference in the survivability of this subset of trauma patients.According to popular studies, the attempted resuscitation of patients in traumatic cardiac arrest in the prehospital care environment should not be pursued due to undo risk to the provider and has been shown to be ineffective. However, after review of current literature, Sherren and colleagues developed and published in a recent edition of Critical Care a detailed treatment algorithm for their helicopter emergency medical service (HEMS) that encourages aggressive resuscitation for patients in traumatic cardiac arrest (TCA) [1]. What is known in a review of the quoted literature is that in the prehospital care environment, the survival rate of TCA patients is 0 to 3.7%, but in newer published studies survivability has risen to 7.5% [2,3].What we already know is that prehospital medical cardiac arrest (MCA) survival is approximately 9.8%, with in-hospital cardiac arrest survival at 24.2% [4]. In MCA, chest compressions, defibrillation, medication, and oxygenation are the mainstay treatment tools. Where the TCA patient differs is that many do not have extensive co-morbidities or coronary artery disease; their arrest is primarily due to one of or a combination of factors: hypovolemia, obstruction of blood flow and hypoxia [5]. In the patient with thoracic trauma, these causes are addressed by well described techniques of thoracostomies, endotracheal intubation and blood products. This is followed by a clamshell thoracotomy, allowing for a better chance for hemorrhage control and treatment of hemopericardium if found. Sherren and colleagues discuss a very well outlined pathophysiology and rationale for TCA survivorship in their article.Although MCA and TCA are not the same diseases, their survival statistics are interesting and possibly some inference can be made when MCA data are more closely observed. It appears that the differences between MCA survival in the prehospital versus a hospital setting, where admitted patients are older with increased morbidities, might be due to the personnel performing the resuscitation. Staffing models for emergency medical services (EMS), especially for HEMS, differ between the US system and the European model. In the US, pre-hospital EMS systems (including most HEMS) are staffed by allied health professionals and not by physicians. In the European model (including Australia) HEMS are staffed by well trained physician/paramedic/nurse teams and this is possibly where the difference occurs for survival for TCA patients.In multiple European studies it was noted that there was a decrease in mortality of trauma patients without a decrease in scene time when a physician was part of the flight crew [6-9]. In the US, less than 5% of HEMS are staffed by physicians, and most of those involved in such teams are in their first few years out of medical school [10]. Thus, no US EMS systems have fully trained physicians as part of their standard ambulance crew. A reasonable question to consider is whether staffing is the reason why TCA statistics differ between the US and European models? Paramedic training teaches needle thoracostomy for suspected tension pneumothorax, which in many jurisdictions do not need online direct physician permission as it is deemed life saving and with limited risk [11]. However, it is well known that in patients with larger chest walls, almost 50% of the time the needle fails to reach the plural space to relieve the obstruction of blood flow caused by the tension pneumothorax. On the contrary, the placement of a tube or finger thoracostomy are very successful and fairly routine in EMS systems staffed with experienced physicians with excellent results [12].The HEMS algorithm of Sherren and colleagues is specific for flight physicians. It cannot be fully applicable to HEMS not staffed by a well trained physician, as the proficiency of thoracotomy is an advanced skill that takes practice and years of anatomical training to be able to perform well. As the authors stated, more study is needed to see if it is the depth of training or the protocols that are the reason for the increases in survivorship from TCA. I do not believe that this algorithm will be promoted in HEMS systems staffed only by paramedics and nurses, as their level of training does not allow for advanced procedures such as these. Therefore, one should expect that prehospital attempts at the resuscitation of the TCA in those systems without physicians on board will remain futile.