Examining professional boundaries between nurses and physicians in neonatal intensive care units

Background

Medical and technological developments, financial constraints and a shortage of physicians have made it necessary to re-examine professional boundaries between physicians and nurses. Israel’s manpower shortage in Neonatal Intensive Care Units (NICUs) has changed the responsibility and authority of nurses. However, these changes have not evolved into a uniform policy defining the division of responsibility between physicians and nurses. This study was designed to examine the work processes and actual division of labor between NICU physicians and nurses; the attitude of physicians and nurses to greater empowerment of the nursing role; and to suggest a model to regulate work processes and develop the role of neonatal nurse specialists in NICUs.

Methods

Open interviews with NICU physician-directors and head nurses and a cross-sectional survey of some 50% of the physicians and nurses at 22 hospital NICUs (N?=?430).

Results

Main problems of NICUs: physician shortage, deficient infrastructures, fragmented work processes. Nurses do not perform many practices allowed to them due to the need for organizational approval and their own unawareness. Conversely, they sometimes conduct procedures and make decisions outside of their authority.Most physicians agree that nurse graduates of Post-Basic Education training (PBE) should be authorized to independently perform such activities as resuscitation and medication balancing while reserving invasive procedures for physicians. It is widely agreed that broadening the authority of nurses would improve the quality of NICU care even though it would increase the nursing workload.

Conclusions

The study provides important input into decisions about authorizing nurses over complete practice areas rather than isolated activities; the need to remove institutional restrictions on tasks currently permitted to nurses; introducing teamwork from within the NICUs, and expanding nursing decision-making. The study reveals that there is a basis on which to to build the role of the neonatal nurse,since most NICU nurses have the suitable academic and clinical training.

     

Defining the need for blood and blood products transfusion following suicide bombing attacks on a civilian population: A level I single-centre experience

Introduction

Knowledge of patterns of blood use in the care of mass casualty settings is important for preparedness of medical centre resources and for maximising survival when blood supplies are limited. Our objectives were to review of our experience with the use of blood products and define the utilisation of blood transfusion following suicide bombing attacks.

Patients and methods

We conducted a retrospective analysis of blood and blood product transfusion following civilian bombing attacks at a level I trauma centre in Jerusalem, Israel from 2000 to 2005. The study group consisted of 137 patients who were admitted following 17 suicide bombing attacks which were carried out in Jerusalem during the 5-year period. Demographic data, number of units of blood and blood products transfused and the need for massive transfusions were recorded and analyzed.

Results

Fifty-three patients received blood transfusions (38.7%). There were 33 males (62.2%) with a median ISS of 13 (range 4–25). These 53 patients received 524 PRBC, 42 WB, and 449 FFP. The mean number of PRBC transfused/admitted patient was 3.82 units (range 0–59). Thirty patients (21.9%) received 236 PRBC (45% of total PRBC) at the first 2 h. The ratio of ordered to transfused blood was 946:524. The FFP:PRBC ratio for all transfused patients was 1:1.17. The number of PRBC transfused per attack correlated with the number of patients admitted per attack. The most commonly transfused blood type was A (52.3%). Only 18 units of uncrossed-matched blood were transfused (3.3% of total). 14 patients (10.2%) received massive transfusions. These patients received 399 PRBC (76.1% of total units transfused) and the average number of PRBC transfused was 28.5/patient (10–59).

Conclusions

More than 1/3 of casualties admitted following civilian bombing attacks received transfusions, most in the first 2 h. Large-scale attacks will require more blood and blood products than small-scale attacks. Twice the number of PRBC ordered than transfused reflects a known trend for over-triage during the initial assessment following bombing attacks. One tenth of patients received massive transfusion.     

Tolvaptan for Volume Management in Heart Failure

Volume management in acute decompensated and chronic heart failure (HF) remains a significant challenge. Although progress has been made in the development of mortality-reducing neurohormonal regimens in the reduced ejection fraction population, no clinical trial has yet demonstrated anything more than symptomatic relief or biomarker reduction with pharmacotherapeutic volume-based interventions made in the acutely decompensated individual or those with evolving outpatient congestion. As the number of patients with HF continues to grow, in addition to HF-related hospitalizations, identifying therapies that have the potential to aid in diuresis more safely and efficaciously is paramount to decreasing inpatient length of stay and preventing unnecessary admissions. More recently, a significant amount of research has been dedicated to the use of vasopressin antagonists, specifically tolvaptan, as adjunctive therapy to loop and thiazide diuretics. Although these agents do not seem to have a pervasive role in fluid management in the acute decompensated and chronic HF populations, they are effective tools to have available for specific clinical situations. This review summarizes the literature surrounding the use of tolvaptan for volume management in congestive HF, as well as offering practical guidance for use of this agent.     

Video-assisted swallowing therapy for patients with Parkinson's disease

BackgroundConventional swallowing therapy for patients with Parkinson's disease (PD) and swallowing difficulties has poor carryover to everyday life. Herein, we test the effectiveness of visual information while treating swallowing disturbances in patients with PD.MethodsForty two non-demented PD patients with swallowing disturbances were randomly divided into two groups. An experimental group received video-assisted swallowing therapy (VAST) and a control group (n = 21) was given conventional therapy. Both groups were given 6 interventional sessions by the same speech and swallowing therapist. Patients in the VAST group were exposed to video of the swallowing process in general as well as of their own, as part of all therapy sessions. Swallowing function was assessed before and post-intervention by fiberoptic endoscopic evaluation of swallowing (FEES). Quality of life, quality of care and the degree of pleasure from eating were also assessed by questioners pre and post-intervention.ResultsThere was a significant improvement in swallowing functions following both interventions. The FEESs demonstrated a significantly greater reduction in food residues in the pharynx in the VAST group compared to the conventional treatment group. There were significant group improvement in some parameters of the quality of life, quality of care and pleasure of eating scales.ConclusionIn cognitively intact patients with PD with swallowing disturbances VAST was associated with improved swallowing related QOL and less food residues in the pharynx.     

Increased rate and greater severity of allergic reactions to insect sting among schoolchildren with atopic diseases

The question of whether atopic diseases are a risk factor for allergic reactions to insect sting is still unresolved. The aim of this study was to evaluate the association between atopic diseases (asthma, allergic rhinitis, atopic eczema) and allergic reactions to insect stings among schoolchildren in Israel. A self‐report questionnaire of the International Study of Asthma and Allergies in Childhood was administered to a national sample of 13–14‐yr‐old schoolchildren. Questions regarding reactions to insect stings were added. A total of 10,021 questionnaires were available for analysis. Among the children who reported insect stings (56.3%), the prevalence of current asthma was 6.0%, of allergic rhinitis, 10.5%, and of atopic eczema, 8.7%, with no significant differences from the whole study population. Among children with any of the atopic diseases, 36.9% reported an allergic reaction to insect sting compared to 24.8% of the non‐atopic children (p < 0.0001). On multivariate analysis, asthma, allergic rhinitis, and atopic eczema were found to be significant risk factors for allergic reactions of any severity. Children in the atopic group had a significantly higher rate of severe allergic reactions than the non‐atopic children, and relatively higher rates of milder ones (p < 0.0001). Asthmatic patients with severe allergic reactions had more parameters of severe asthma than asthmatic patients with mild or no reactions. In conclusions, allergic diseases are associated with a higher rate and greater severity of allergic reactions to insect sting in children. The severity of the allergic reaction is related to the severity of the asthma symptoms.     

A prospective study of limiting longstanding illness in early adulthood

BACKGROUND: Chronic illness and disability are of increasing public health importance but little is known about the lifetime influences involved in their onset and progression. We aim to (i) establish whether an individual's rating of limiting illness is stable over a 10-year period from age 23 to 33; (ii) assess the relationship between childhood and adult disability; and (iii) identify lifecourse influences on limiting illness in early adulthood. METHODS: Data were from the 1958 British birth cohort, including the original birth survey and follow-ups at ages 7, 11, 16, 23 and 33 years. Limiting longstanding illness was the outcome at both ages 23 and 33. Potential predictors included childhood health and physical development, socioeconomic conditions in early life and adulthood, and behavioural factors. We estimated the effect of potential explanatory factors using logistic regression, in both univariate and multivariate analyses, separately for limiting illness at 23 and 33 years. RESULTS: Prevalence of limiting illness increased from 5.1% (men) and 4.1% (women) at age 23 to 6% for both sexes at age 33. Risk of limiting illness at age 33 was greater for those reporting an illness at age 23 (29.4%, compared with 4.7% of those without illness), though the majority (66%) of 33-year limiting illnesses had no previous record at age 23 or for childhood. Multivariate analysis of limiting illness at age 23 confirmed the high risk for those with childhood disability and also established two further major predictors, namely, injury (adjusted odds ratio [OR] = 1.42, 95% CI: 1.09-1.86) and intermediate socio-emotional status (adjusted OR = 1.73, 95% CI: 1.29-2.31). Additional risks were identified for limiting illness at age 33, including: (i) injury in the preceding 10 years (adjusted OR = 1.55, 95% CI : 1.18-2.04); (ii) body mass index (BMI), for which the relationship was non-linear, with elevated risks for the underweight (adjusted OR = 1.53, 95% CI: 1.03-2.26) and overweight (OR = 1.28, 95% CI: 0.87-1.89); (iii) childhood disadvantage at either or both ages 7 and 11 (adjusted OR = 1.53, 95% CI : 1.07-2.17); and (iv) height at age 7, with a significant non-linear relationship (the adjusted OR for height less than 15th percentile was 1.43 and for height more than the 85th percentile, 1.30). CONCLUSIONS: Both childhood and adult factors predict limiting illness in early adulthood. Childhood is important because some adult illnesses originate in early life, and also because childhood environment influences the risk of adult limiting illness several years later. Our findings suggest that studies seeking to understand the causes of limiting illness, that currently tend to focus exclusively on contemporary factors, need also to consider the contribution of environment in early life.     

Dichotomous or categorical response? Analysing self-rated health and lifetime social class

BACKGROUND: Self-rated health is a commonly used measure of health status, usually having three to five categories. The measure is often collapsed into a dichotomous variable of good versus less than good health. This categorization has not yet been justified. METHODS: Using data from the 1958 British birth cohort, we examined the relationship between socioeconomic conditions, indicated by occupational class at four ages, and self-rated health. Results obtained for a dichotomous variable using logistic regression were compared with alternative methods for ordered categorical variables including polytomous regression, cumulative odds, continuation ratio and adjacent categories models. RESULTS AND CONCLUSIONS: Findings concerning the relationship between socioeconomic position and self-rated health yielded by a logistic regression model were confirmed by alternative statistical methods which incorporate the ordered nature of self-rated health. Similarity of results was found regarding size and significance of main effects, type of association and interactive effects.     

Occupational exposure to cotton dust in cottonseed oil mills

Air samples were collected at breathing height in the hulling-separation department of a modern cottonseed oil mill in Uzbekistan. The average elutriated mass concentration measured by standard cotton dust samplers was 4.6 mg/m3, much lower than the average total dust concentration measured by stationary personal samplers, 12.49 mg/m3, and by personal samplers attached to workers, 14.53 mg/m3. Differences in readings among the vertical elutriators, stationary personal samplers, and roving personal samplers are attributed to the distinct sampling nature and dynamics of these samplers. The data suggest that most of the dust consisted of particles larger than 15 microm, the particle size cutoff of the vertical elutriator. Differences in readings among stationary and roving personal samplers are statistically significant, presumably representing biased sampling by the roving personal samplers of regions characterized by high dust concentration (due to machines malfunctioning), the nonstatic nature of the sampling, and the interaction between the sampler and the worker (the personal cloud). Cotton dust concentrations in the hulling-separation room were nonuniform, peaking in front of and between the huller-separator pairs. The high total mass readings show that workers were exposed to very high levels of nonthoracic airborne dust, which upon inhalation tends to deposit in the extrathoracic airways. The high elutriated mass concentrations suggest that workers were exposed to respirable cotton dust at levels higher than 1 mg/m3 mean concentration, the current Occupational Safety and Health Administration (OSHA) Permissible Exposure Limit (PEL) for cotton dust. Regressions between dust concentrations measured by stationary vertical elutriators and by personal samplers attached to workers serve for estimating the potential occupational exposure to cotton dust of workers in the hulling-separation room.     

Generalized singular value decomposition for comparative analysis of genome-scale expression data sets of two different organisms

We describe a comparative mathematical framework for two genome-scale expression data sets. This framework formulates expression as superposition of the effects of regulatory programs, biological processes, and experimental artifacts common to both data sets, as well as those that are exclusive to one data set or the other, by using generalized singular value decomposition. This framework enables comparative reconstruction and classification of the genes and arrays of both data sets. We illustrate this framework with a comparison of yeast and human cell-cycle expression data sets.