Nurses' critical event risk assessments: a judgement analysis

Aims. To explore and explain nurses’ use of readily available clinical information when deciding whether a patient is at risk of a critical event. Background. Half of inpatients who suffer a cardiac arrest have documented but unacted upon clinical signs of deterioration in the 24 hours prior to the event. Nurses appear to be both misinterpreting and mismanaging the nursing‐knowledge ‘basics’ such as heart rate, respiratory rate and oxygenation. Whilst many medical interventions originate from nurses, up to 26% of nurses’ responses to abnormal signs result in delays of between one and three hours. Methods. A double system judgement analysis using Brunswik's lens model of cognition was undertaken with 245 Dutch, UK, Canadian and Australian acute care nurses. Nurses were asked to judge the likelihood of a critical event, ‘at‐risk’ status, and whether they would intervene in response to 50 computer‐presented clinical scenarios in which data on heart rate, systolic blood pressure, urine output, oxygen saturation, conscious level and oxygenation support were varied. Nurses were also presented with a protocol recommendation and also placed under time pressure for some of the scenarios. The ecological criterion was the predicted level of risk from the Modified Early Warning Score assessments of 232 UK acute care inpatients. Results. Despite receiving identical information, nurses varied considerably in their risk assessments. The differences can be partly explained by variability in weightings given to information. Time and protocol recommendations were given more weighting than clinical information for key dichotomous choices such as classifying a patient as ‘at risk’ and deciding to intervene. Nurses’ weighting of cues did not mirror the same information's contribution to risk in real patients. Nurses synthesized information in non‐linear ways that contributed little to decisional accuracy. The low‐moderate achievement (R_a) statistics suggests that nurses’ assessments of risk were largely inaccurate; these assessments were applied consistently among ‘patients’ (scenarios). Critical care experience was statistically associated with estimates of risk, but not with the decision to intervene. Conclusion. Nurses overestimated the risk and the need to intervene in simulated paper patients at risk of a critical event. This average response masked considerable variation in risk predictions, the need for action and the weighting afforded to the information they had available to them. Nurses did not make use of the linear reasoning required for accurate risk predictions in this task. They also failed to employ any unique knowledge that could be shown to make them more accurate. The influence of time pressure and protocol recommendations depended on the kind of judgement faced suggesting then that knowing more about the types of decisions nurses face may influence information use. Relevance to clinical practice. Practice developers and educators need to pay attention to the quality of nurses’ clinical experience as well as the quantity when developing judgement expertise in nurses. Intuitive unaided decision making in the assessment of risk may not be as accurate as supported decision making. Practice developers and educators should consider teaching nurses normative rules for revising probabilities (even subjective ones) such as Bayes’ rule for diagnostic or assessment judgements and also that linear ways of thinking, in which decision support may help, may be useful for many choices that nurses face. Nursing needs to separate the rhetoric of ‘holism’ and ‘expertise’ from the science of predictive validity, accuracy and competence in judgement and decision making.     

A systematic review of health-related quality of life and hearing aids: final report of the American Academy of Audiology Task Force On the Health-Related Quality of Life Benefits of Amplification in Adults

This is the final report of the American Academy of Audiology Task Force on the Health-Related Quality of Life (HRQoL) Benefits of Amplification in Adults. A systematic review with meta-analysis examined evidence pertaining to the use of hearing aids for improving HRQoL for adults with sensorineural hearing loss (SNHL). Relevant search strings applied to the CENTRAL, CINAHL, Cochrane Reviews, ComDisDome, EBMR, and PubMed databases identified randomized controlled trial, quasi-experimental, and nonexperimental pre-post test designed studies. Sixteen studies met a priori criteria for inclusion in this review. A random-effects meta-analysis showed differential results for generic versus disease-specific HRQoL measures for within- and between-subject designs. Although generic measures used for within-subject designs did not demonstrate HRQoL benefits from hearing aids, mean effect sizes and confidence intervals for within-subject designs and disease-specific instruments suggested that hearing aids have a small-to-medium impact on HRQoL. Further, the between-subject studies supported at least a small effect for generic measures, and when measured by disease-specific instruments, hearing aids had medium-to-large effects on adults' HRQoL. This review concludes that hearing aids improve adults' HRQoL by reducing psychological, social, and emotional effects of SNHL. Future studies should include control groups using randomized controlled trials.     

The intimidation of British pediatricians

British pediatricians who diagnose and treat child abuse cases have come under attack by the British press and by parents who have been investigated for possible abuse. Now the General Medical Council also is intimidating these pediatricians. The General Medical Council is the licensing authority for physicians in the United Kingdom. This has resulted in fewer pediatricians being willing to care for abused children or to testify in child abuse cases. In the United States, the recent recognition of the pediatric subspecialty of child abuse pediatrics should help set standards for child abuse medical evaluation and testimony.     

Human bullous pemphigoid antigen 2 transgenic skin elicits specific IgG in wild-type mice

Bullous pemphigoid antigen 2 (BPAG2) is targeted by autoantibodies in patients with bullous pemphigoid (BP), and absent in patients with one type of epidermolysis bullosa (OMIM #226650). A keratin 14 promoter construct was used to produce transgenic (Tg) mice appropriately expressing human BPAG2 (hBPAG2) in murine epidermal basement membrane (BM). Grafts of Tg skin placed on gender-matched, syngeneic wild type (Wt) or major histocompatibility complex I (MHC I)-/- mice elicited IgG that bound human epidermal BM and BPAG2. Production of such IgG in grafted mice was prompt (detectable within 16+/-2 days), robust (titer > or = 1,280), durable (present > or = 380 days), and correlated with the involution and loss of Tg skin grafts. MHC II-/- mice grafted with Tg skin did not develop anti-hBPAG2 IgG or graft loss indicating that MHC II:CD4+ T cell interactions were crucial for these responses. Tg skin grafts on Wt mice developed neutrophil-rich infiltrates, dermal edema, subepidermal blisters, and deposits of immunoreactants in epidermal BM. This model shows fidelity to alterations seen in patients with BP, has relevance to immune responses that may arise in patients with epidermolysis bullosa following BPAG2 gene replacement, and can be used to identify interventions that may block production of IgG against proteins in epidermal BM.     

A new instrument to aid the lateral tarsal sling procedure

We describe a new surgical instrument and its use in the lateral tarsal sling procedure. We reviewed the charts of 23 cases of such surgery over 5 years and found its use to be an effective means of correcting horizontal eyelid laxity, with a low rate of complications. This approach provides a safe and effective alternative to the lateral tarsal strip procedure.     

Brain lymphoma: usefulness of the magnetic resonance spectroscopy

The diagnosis of primary central nervous system lymphoma (PCNSL) should always be considered as an emergency because of the therapeutic consequences it implies. In immunocompetent patients, it relies on stereotactic biopsy. Unfortunately, clinical and radiological features may be misleading and delay the diagnostic procedure. The case we report here illustrates the contribution of magnetic resonance spectroscopy in the diagnostic approach of a very atypical PCNSL.     

Treatment of acne using a 3-milligram drospirenone/20-microgram ethinyl estradiol oral contraceptive administered in a 24/4 regimen: a randomized controlled trial

OBJECTIVE: To assess the efficacy of the combined oral contraceptive containing 3-mg drospirenone/20-microgram ethinyl estradiol (3-mg drospirenone/20-microgram ethinyl estradiol) administered as 24 consecutive days of active treatment after a 4-day hormone-free interval (24/4 regimen) compared with placebo for the treatment of moderate acne vulgaris. METHODS: Healthy females aged 14-45 years with moderate acne were randomized in this double-blind study to 3-mg drospirenone/20-microgram ethinyl estradiol (n=270) or placebo (n=268) for six cycles of 28 days. The primary outcome measures of acne lesion counts and Investigator Static Global Assessment scale ratings were assessed at baseline and during cycles 1, 3, and 6. RESULTS: The percentage reduction from baseline to endpoint for total lesions is 46.3% for 3-mg drospirenone/20-microgram ethinyl estradiol 24/4 combination oral contraceptive group and 30.6% for placebo group (P<.001). The likelihood of participants in the 3-mg drospirenone/20-microgram ethinyl estradiol 24/4 regimen group having "clear" or "almost clear" skin as rated by the investigators at endpoint was about threefold (odds ratio 3.13, 95% confidence interval 1.69-5.81; P=.001) greater than in the placebo group. The 3-mg drospirenone/20-microgram ethinyl estradiol 24/4 regimen was well tolerated. CONCLUSION: The low-dose combined oral contraceptive containing 3-mg drospirenone/20-microgram ethinyl estradiol administered in a 24/4 regimen significantly reduced acne lesion counts more effectively than placebo and demonstrated greater improvement in the Investigator Static Global Assessment rating of acne. The safety profile was consistent with low-dose combined oral contraceptive use.