Strategies to improve the patient safety outcome indicator: preventing or reducing falls

In response to our agency exceeding the national benchmark rates for "Emergent Care for Injury Caused by Fall or Accident at Home," Alliance Visiting Nurse Association & Hospice developed a program to assess, prevent, or decrease the risk of falls in our mostly elderly and/or chronically ill population. Using the Tinetti Assessment score as the starting point, we developed a program of assessment, education, and follow-up that significantly reduced the number of patients requiring care for fall-related injuries.     

Emergency drills in obstetrics: reducing risk of perinatal death or permanent injury

This article describes the need for mock emergency drills in perinatal emergencies such as shoulder dystocia, maternal hemorrhage, and emergency cesarean section. Effective drills are a patient safety initiative to reduce medical errors and adverse events during the antepartum, intrapartum, and postpartum periods. Successful strategies are identified from other fields of practice to improve patient outcomes. Realistic, institutional specific scenarios for mock emergency drills result in improved team behaviors leading to better outcomes for mothers and infants.     

Efficacy of electrical stimulation in preventing or reducing subluxation of the shoulder after stroke: a meta-analysis

After stroke, up to 81% of individuals develop shoulder subluxation, a condition frequently associated with poor upper limb function. Recently, electrical stimulation has been applied to shoulder muscles to treat shoulder subluxation. The purpose of this meta-analysis was to examine the efficacy of surface electrical stimulation for the prevention or reduction of shoulder subluxation after stroke. A meta-analysis of all eligible randomised or quasi-randomised trials of electrical stimulation for the treatment of shoulder subluxation identified by computerised and hand searches of the literature was carried out. The primary outcome measure of interest was subluxation. Seven (four early and three late) trials met the inclusion criteria. The mean PEDro score out of 10 for quality of the methods was 5.8 for the four early trials and 4.3 for the three late trials. Data were pooled when subluxation was measured in millimetres. Analysis found that, when added to conventional therapy, electrical stimulation prevented on average 6.5mm of shoulder subluxation (weighted mean difference, 95% CI 4.4 to 8.6) but only reduced it by 1.9mm (weighted mean difference, 95% CI -2.3 to 6.1) compared with conventional therapy alone. Therefore, evidence supports the use of electrical stimulation early after stroke for the prevention of, but not late after stroke for the reduction of, shoulder subluxation.     

Spinal cord injury: preventing secondary injury.

Spinal cord injury is devastating to the victim, as well as being costly in terms of medical expenses, lost wages, and lost independence. The initial damage to the spinal cord results from several mechanisms of injury--flexion, extension, compression, penetration, rotation, and the disease process. When the spinal cord is injured and there is necrosis of the nervous tissue, no regeneration of that tissue occurs. Unlike in the peripheral nervous system, where regeneration is possible, the spinal cord is part of the central nervous system, as is the brain. The spinal cord extends from the base of the skull to the L1 vertebrae: the cervical levels innervate the diaphragm and muscles of the arms; the thoracic levels innervate the muscles of the chest and abdomen; and the lumbar and sacral levels innervate the muscles of the legs. In addition, the sacral levels are responsible for bowel, bladder, and sexual function. The higher the level of injury, the more severe the loss of function because, not only is the level of injury affected, but also the levels below. Injury occurs by initial trauma to the surrounding ligaments, bones, and muscles, which then affect the spinal cord. There may be total loss of function with damage completely across the cord or partial loss of function with damage affecting only part of the cord. No current treatment can reverse this initial injury, which causes irreversible damage within minutes of injury. Secondary damage occurs as the injury spreads over several hours. Treatment can help prevent this secondary damage.     

Assessment of drug-induced liver injury in clinical practice

Currently, pharmaceutical preparations are serious contributors to liver disease, with hepatotoxicity ranking as the most frequent cause for acute liver failure and post-marketing regulatory decisions. The diagnostic approach of drug-induced liver injury (DILI) is still rudimentary and inaccurate because of the lack of reliable markers for use in general clinical practice. To incriminate any given drug in an episode of liver dysfunction is a step-by-step process that requires a high degree of suspicion, compatible chronology, awareness of the drug's hepatotoxic potential, the exclusion of alternative causes of liver damage, and the ability to detect the presence of subtle data that favour a toxic aetiology. Clinical and laboratory data may also be assessed with algorithms or clinical scales, which may add consistency to the clinical judgment by translating the suspicion into a quantitative score. The CIOMS/RUCAM instrument is considered at present the best method for assessing causality in DILI, although it could be improved through the use of large database of bona fide DILI cases for validation criteria.     

Predicting and preventing post-herpetic neuralgia: Are current risk factors useful in clinical practice?

Post-herpetic neuralgia (PHN) following acute herpes zoster remains a significant cause of neuropathic pain especially in the elderly. Early treatment of the zoster rash with antiviral agents, such as aciclovir remains one of the few measures proven to reduce the incidence and duration of PHN albeit only in a subset of patients. It is therefore crucial that the physician who first sees a case of zoster identifies those patients who are most likely to develop long-term pain and treats them accordingly. In particular, prodrugs such as famciclovir and valaciclvoir may be more beneficial in reducing PHN than the shorter acting aciclovir, but can be more expensive. Measures that could be used to predict patients likely to develop PHN would also facilitate the evaluation of early use of antiepileptic, anti-inflammatory and analgesic agents in the prevention of PHN. In a prospective study of 280 herpes zoster (HZ) cases seen by the general practitioner (GP) we evaluated the predictive value of five clinical factors identified in clinical trials as associated with a higher likelihood of PHN. A visual analogue score (VAS) over 5 and/or age over 50 correctly identified all subjects with PHN at 3 and 6 months, respectively. However, the specificity of this prediction was low because as many as 81% and 85% of those aged over 50 recovered within 3 and 6 months, respectively. Better methods are needed to identify patients over 50 at most risk of PHN that enable GPs to better allocate their resources with respect to HZ treatment.     

Evidence-based clinical practice guideline: inhaled nitric oxide for neonates with acute hypoxic respiratory failure

Inhaled nitric oxide (INO) is a colorless, odorless gas that is also a potent pulmonary vasodilator. When given via the inhaled route it is a selective pulmonary vasodilator. INO is approved by the United States Food and Drug Administration (FDA) for the treatment of term and near-term neonates with hypoxemic respiratory failure associated with clinical or echocardiographic evidence of pulmonary arterial hypertension. A systematic review of the literature was conducted with the intention of making recommendations related to the clinical use of INO for its FDA-approved indication. Specifically, we wrote these evidence-based clinical practice guidelines to address the following questions: (1) What is the evidence for labeled use? (2) What are the specific indications for INO for neonates with acute hypoxemic respiratory failure? (3) Does the use of INO impact oxygenation, mortality, or utilization of extracorporeal membrane oxygenation (ECMO)? (4) Does INO affect long-term outcomes? (5) Is INO cost-effective therapy? (6) How is the appropriate dosing regimen and dose response to INO established? (7) How is the dose of INO titrated and weaned? (8) Which INO delivery system should be used? (9) How should INO be implemented with different respiratory support devices? (10) What adverse effects of INO should be monitored, and at what frequency? (11) What physiologic parameters should be monitored during INO? (12) Is scavenging of gases necessary to protect the caregivers? Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scoring system, 22 recommendations are developed for the use of INO in newborns.     

Evidence-based management practice: reducing falls in hospital

This paper reports on a falls prevention and management program at one regional Western Australian hospital. The report focuses on the processes and outcomes of a quality management initiative to reduce falls in hospital to illustrate the nexus between research and quality improvement in clinical practice. The Falls Prevention program was based on statistical evidence of the level of risk in the hospital and development of an evidence-based multidimensional, multidisciplinary program to reduce the risks of falling and the number of falling events. Evaluative data demonstrate the effectiveness of the program in terms of a substantial reduction in falls. The program illustrates the value of evidence-based practice, particularly in relation to evidence-based management practice. It supports the merits of creating an organisational climate where all clinicians are encouraged to use research data to plan strategies for quality improvement and risk management and, in the process, advance clinical nursing knowledge development.     

Effectiveness of internal quality assurance programmes in improving clinical practice and reducing costs

Rationale, aims and objectives  To assess the effectiveness of internal initiatives to improve quality as compared with external feedback, and as compared with a control group.
Method  Ten primary health centres were randomly selected from the centres in the Murcia's Region and were randomly assigned into three groups: G1 committed themselves to the improvement; G2 composed by two subgroups: with and without quality improvement (QI) activities – received external feedback; G3 received no intervention. Quality of common cold management was measured in a random sample of 50 patients per centre before and after interventions. Effect was assessed comparing criteria compliance and the cost of treatments for common cold in the three groups.
Results  G1 and G2 subgroup with internal QI improved significantly in all criteria, and in G1 average treatment cost decreased by 60% ( P  < 0.01). G3 improved only in one criterion. Estimated yearly savings in treatment costs for common cold, for a centre with internal QI, were €12 193.83 and it would be €1 817 004.65 for the 30 centres in the Region.
Conclusions  Internally assumed QI activities were significantly more effective than external feedback. Besides, the high cost of deficient quality provides a wide margin to invest with benefits in the promotion of internal QI programmes.     

间隔式充气防压疮床的研制与临床应用

目的 设计并制作了间隔式充气防压疮床,并对其临床防治效果进行评价.方法 选取患者173例,随机分为治疗组(87例)和对照组(86例).对照组采用常规治疗和护理方法,治疗组在对照组的基础上同时加用自行研制的间隔式气垫床干预治疗.结果 治疗组总有效率为96.6％,明显高于对照组的76.7％ (x2 =21.01,P＜0.01);治疗组痊愈时间明显短于对照组(t=14.9,P＜0.01),差异具有显著统计学意义.结论 应用气垫床对防治压疮有积极作用,可以缩短患者压疮治疗时间,显著提高治愈率.     

缺氧诱导因子-1与缺氧缺血性肾损伤

缺氧诱导因子-1(hypoxia inducible factor-1,HIF-1)是细胞在缺氧条件下产生的具有转录活性的核蛋白,能与靶基因结合,通过转录和转录后调控使机体对缺氧、缺血产生适应性反应。近年来,HIF-1在肾脏缺氧缺血性损伤中的作用也逐渐受到人们的关注。本文就HIF-1的生物学特点,对靶基因的调节及在缺氧缺血性肾损伤中的作用作一综述。     

The nursing shortage: dynamics and solutions. A supportive clinical practice model

In a large VA teaching hospital, the primary nursing care delivery model is established with an all-RN staff. Several new initiatives and incentives have been implemented to maintain nurse satisfaction during this period of nurse shortage, but the primary nurse's relationship with her or his patient is the most satisfying and rewarding opportunity in this setting. The professional profile of the nurse staff reflects high academic preparation, certification in clinical area of practice, and involvement in nursing organizations. Primary nursing is successful because of the availability of support services, which enable the nurse to remain with the patient on the nursing unit. The primary nursing care delivery model and staffing were evaluated and revised to include licensed vocational (practical) nurses as associate nurses. Nurses on staff affirm their authority and autonomy to make and carry out clinical decisions about the nursing care of their primary patients. Physicians recognize nurses as the co-primary care provider in a clinical practice atmosphere of mutual respect and collaboration. New opportunities for professional growth and self-actualization enrich the work environment.