RESUMEN
OBJECTIVE: To compare the effectiveness of an antishear mattress overlay (ASMO) with a standard ambulance stretcher surface in reducing pressure and shear and increasing patient comfort. METHODS: In this randomized, crossover design, adults in three body mass index categories served as their own controls. Pressure/shear sensors were applied to the sacrum, ischial tuberosity, and heel. The stretcher was placed in sequential 0°, 15°, and 30° head-of-bed elevations with and without an ASMO. The ambulance traveled a closed course, achieving 30 mph, with five stops at each head-of-bed elevation. Participants rated discomfort after each series of five runs. RESULTS: Thirty individuals participated. Each participant had 30 runs (15 with an ASMO, 15 without), for a total of 900 trial runs. The peak-to-peak shear difference between support surfaces was -0.03 N, indicating that after adjustment for elevation, sensor location, and body mass index, peak shear levels at baseline (starting pause) were 0.03 N lower for the ASMO than for the standard surface ( P = .02). The peak-to-peak pressure difference between surfaces was -0.16 mm Hg, indicating that prerun peak-to-peak pressure was 0.16 mm Hg lower with the ASMO versus standard surface ( P = .002). The heel received the most pressure and shear. Discomfort score distributions differed between surfaces at 0° ( P = .004) and 30° ( P = .01); the overall score across all elevations was significantly higher with the standard surface than with the ASMO ( P = .046). CONCLUSIONS: The ASMO reduced shear, pressure, and discomfort. During transport, the ambulance team should provide additional heel offloading.
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Servicios Médicos de Urgencia , Úlcera por Presión , Adulto , Humanos , Estudios Cruzados , Talón , Presión , Lechos , Úlcera por Presión/prevención & controlRESUMEN
BACKGROUND: ARDS remains a source of significant morbidity and mortality in the critically ill patient. The mainstay of therapy entails invasive mechanical ventilation utilizing a lung-protective strategy designed to limit lung injury associated with excessive stress and strain while the underlying etiology of respiratory failure is identified and treated. Less is understood about what to do once conventional ventilation parameters have been optimized but the patient's respiratory status remains unchanged or worsens. In 2015, a protocolized, stepwise approach to mechanical ventilation with partially automated and clearly defined thresholds for management changes was implemented at our institution. We hypothesized that, by identifying appropriate patients earlier, time-to-escalation and rescue therapy implementation would be shortened. METHODS: Subjects with severe ARDS, treated with prone positioning based on our institution's protocolized approach from December 2013 to August 2016 were included. Their baseline characteristics, severity of illness scores, and mechanical ventilation parameters were collected and analyzed. RESULTS: Baseline characteristics, tidal volumes, PaO2 /FIO2 , duration of ventilation after proning, and mortality were similar in both groups. Median (interquartile range [IQR]) PEEP at the time of proning was higher after the protocol implementation (12.5 cm H2O [IQR 6.5-19.4] vs 18 cm H2O [IQR 10-22], P = .386), and mean (IQR) respiratory system driving pressure was lower (16 cm H2O [IQR 13-36.2] vs 12 cm H2O [IQR 9-19.6], P = .029). Median (IQR) time from refractory hypoxemia identification to proning was shorter after protocol implementation (42.2 h [IQR 6.83-347.2] vs 16.3 h [IQR 1-99.7], I = .02), and PaO2 /FIO2 at 1 h after proning was higher. ICU and hospital LOS were shorter after the protocol implementation. CONCLUSIONS: Following the implementation of an early, evidence-based, protocolized approach to optimizing mechanical ventilation, subjects with true refractory hypoxemia were identified earlier and time to proning was significantly shorter. Despite improvement in the evaluation and management of refractory hypoxemia as well as time to initiation of prone positioning, mortality was unchanged and there was variation in the duration of the position.
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Protocolos Clínicos , Hipoxia/terapia , Respiración Artificial/métodos , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Posicionamiento del Paciente , Síndrome de Dificultad Respiratoria/terapia , Insuficiencia Respiratoria/terapia , Estudios Retrospectivos , Volumen de Ventilación Pulmonar , Resultado del TratamientoRESUMEN
Preventing, identifying, and treating deep tissue injury (DTI) remains a challenge. PURPOSE: The purpose of the current research was to describe the characteristics of DTIs and patient/care variables that may affect their development and outcomes at the time of hospital discharge. METHODS: A retrospective, descriptive, single-site cohort study of electronic medical records was conducted between October 1, 2010, and September 30, 2012, to identify common demographic, intrinsic (eg, mobility status, medical comorbidities, and incontinence), extrinsic (ie, surgical and procedural events, medical devices, head-of-bed elevation), and care and treatment factors related to outcomes of hospital-acquired DTIs; additional data points related to DTI development or descriptive of the sample (Braden Scale scores and subscale scores, hospital length of stay [LOS], intensive care unit [ICU] LOS, days from admission to DTI, time in the operating room, serum albumin levels, support surfaces/specialty beds, and DTI locations) also were retrieved. DTI healing outcomes, grouped by resolved, partial-thickness/stable, and full-thickness/unstageable, and 30 main patient/treatment variables were analyzed using Kruskal-Wallis, chi-squared, and Fischer exact tests. RESULTS: One hundred, seventy-nine (179) DTIs occurred in 141 adult patients (132 in men, 47 in women; mean patient age 64 [range 19-94]). Of those patients, 110 had a history of peripheral vascular disease and 122 had hypertension. Sixty-nine (69) DTIs were documented in patients who died within 1 year of occurrence. Most common DTI sites were the coccyx (47 [26%]) and heel (42 [23%]); 41 (22%) were device-related. Median hospital LOS was 23 (range 4-258) days and median ICU LOS was 12 (range 1-173) days; 40 DTIs were identified before surgery and 120 after a diagnostic or therapeutic procedure. Data for DTI outcome groups at hospital discharge included 28 resolved, 131 partial-thickness/stable, and 20 full-thickness/unstageable; factors significantly different between outcome groups included mechanical ventilation (15/42/12; P = .01), use of a feeding tube (15/46/12; P = .02), anemia (14/30/9; P = .005), history of cerebrovascular accident (12/27/7; P = .03), hospital LOS (67/18/37.5; P <.001), ICU LOS (23/10/12; P = .03), time-to-event (13.5/8/9; P = .001), vasopressor use after DTI (13/31/11; P = .003), low-air-loss surface (10/9/3; P = .005), and device-related (14/24/4; P = .002). CONCLUSION: DTI risk factors mirrored those of other PUs, but progression to full-thickness injury was not inevitable. Early and frequent assessment and timely intervention may help prevent DTI progression.
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Úlcera por Presión/diagnóstico , Úlcera por Presión/enfermería , Adulto , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Estudios de Cohortes , Femenino , Humanos , Enfermedad Iatrogénica/prevención & control , Unidades de Cuidados Intensivos/organización & administración , Unidades de Cuidados Intensivos/normas , Unidades de Cuidados Intensivos/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Úlcera por Presión/prevención & control , Estudios Retrospectivos , Factores de RiesgoRESUMEN
STUDY DESIGN: Randomized controlled trial. OBJECTIVE: The aim of the study was to compare and contrast the restrictiveness and tissue-interface pressure (TIP) characteristics of 2 standard and 2 adjustable cervical collars. SUMMARY OF BACKGROUND DATA: This study compared the restrictiveness and TIP of 4 commercially available cervical collars (2 standard and 2 adjustable). Adjustable collars offer potential advantages of individualized fit for patients and decreased inventory for institutions. The overall goal was to determine whether the adjustable collars provided the same benefits of cervical range-of-motion (CROM) restriction as the standard collars without increasing TIP and risk of pressure-related complications. METHODS: A total of 48 adult volunteer subjects (24 men and 24 women) were fitted with 4 collars (Aspen, Aspen Vista, Miami J, and Miami J Advanced) in random order. Data collection included assessment of CROM restrictiveness and measurement of TIP on the mandible and occiput in upright and supine positions. The experimental, repeated measures design stratified the sample by body mass index (BMI) and sex. RESULTS: All collars restricted CROM as compared with no collar (P ≤ 0.001 each). Aspen was more restrictive than Aspen Vista and Miami J in 4 movement planes (P ≤ 0.003 each), but not significantly different from Miami J Advanced. The Miami J standard collar was associated with significantly lower peak TIPs on all sites and in all positions compared with Aspen (P ≤ 0.001), Miami J Advanced (P < 0.001), and Aspen Vista (P = 0.01 for mandible site and upright position, P < 0.001 for remaining sites and positions). Increased peak TIP correlated with high BMI across all collar types, but was significantly lower for the Miami J collar than the Aspen collar. CONCLUSION: All collars, compared with no collar, significantly restricted CROM. Although the collar-to-collar comparisons were statistically significant, the differences may have little clinical significance in the acutely injured trauma patient. The Miami J standard collar had the lowest overall TIP in both sites and positions. Ongoing effort should be devoted to staff education in proper sizing and fit, particularly for patients with high BMI.
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Vértebras Cervicales/fisiopatología , Aparatos Ortopédicos/efectos adversos , Aparatos Ortopédicos/estadística & datos numéricos , Rango del Movimiento Articular/fisiología , Adolescente , Adulto , Anciano , Diseño de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Úlcera por Presión , Adulto JovenRESUMEN
PURPOSE: Our aim was to explore reasons for physician variability in decisions to limit life support in the intensive care unit (ICU) utilizing qualitative methodology. METHODS: Single center study consisting of semi-structured interviews with experienced physicians and nurses. Seventeen intensivists from medical (n = 7), surgical (n = 5), and anesthesia (n = 5) critical care backgrounds, and ten nurses from medical (n = 5) and surgical (n = 5) ICU backgrounds were interviewed. Principles of grounded theory were used to analyze the interview transcripts. RESULTS: Eleven factors within four categories were identified that influenced physician variability in decisions to limit life support: (1) physician work environment-workload and competing priorities, shift changes and handoffs, and incorporation of nursing input; (2) physician experiences-of unexpected patient survival, and of limiting life support in physician's family; (3) physician attitudes-investment in a good surgical outcome, specialty perspective, values and beliefs; and (4) physician relationship with patient and family-hearing the patient's wishes firsthand, engagement in family communication, and family negotiation. CONCLUSIONS: We identified several factors which physicians and nurses perceived were important sources of physician variability in decisions to limit life support. Ways to raise awareness and ameliorate the potentially adverse effects of factors such as workload, competing priorities, shift changes, and handoffs should be explored. Exposing intensivists to long term patient outcomes, formalizing nursing input, providing additional training, and emphasizing firsthand knowledge of patient wishes may improve decision making.
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Toma de Decisiones , Unidades de Cuidados Intensivos , Cuidados para Prolongación de la Vida , Pautas de la Práctica en Medicina/estadística & datos numéricos , Privación de Tratamiento , Actitud del Personal de Salud , Competencia Clínica , Enfermería de Cuidados Críticos , Femenino , Humanos , Entrevistas como Asunto , Masculino , Política Organizacional , Pase de Guardia , Relaciones Profesional-Familia , Relaciones Profesional-Paciente , Investigación Cualitativa , Carga de TrabajoRESUMEN
PURPOSE: To improve identification of risk factors for pressure ulcer development and enhance targeted interventions and prevention strategies. SUBJECTS AND SETTING: The records of 12,566 adult patients hospitalized in intensive or progressive care units within Mayo Clinic were analyzed. Inclusion criteria were Braden Scale of 18 or less during the hospitalization; exclusion criteria were preexisting pressure ulcer or length of stay less than 24 hours. METHODS: This study is a retrospective cohort analysis of electronic medical record data from January 1, 2007, to December 31, 2007. Only iatrogenic stage 2 to 4 pressure ulcers were considered as incident events. Demographic and clinical data were extracted from the medical record, including total Braden Scale score and Braden subscale scores at hospital admission, length of stay, admission to the intensive care unit at the time of hospitalization, and presence of acute respiratory failure, acute renal failure, or diabetes. Time to event was calculated based on time from admission to pressure ulcer occurrence or to hospital discharge. RESULTS: Four hundred sixteen (3.3%) of patients developed a pressure ulcer during their hospitalizations. The Braden Scale score total by itself was found to be highly predictive of pressure ulcer development (P ≤ .0001, C = 0.71), as were all individual subscores. The friction/shear subscale had the greatest predictive power among Braden Scale scores (subscores and total score) (C = 0.83). The multivariate model after selection included 5 Braden Scale subscales, surgery, and acute respiratory failure (C = 0.91). CONCLUSIONS: The total Braden Scale score is predictive of pressure ulcer development but does not assist the clinician to develop an individualized targeted prevention plan. In contrast, the use of subscale scores can enhance prevention programs and resource utilization by focusing care on the risk factors specific to the individual patient.
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Enfermedad Crítica/enfermería , Úlcera por Presión/clasificación , Úlcera por Presión/epidemiología , Prevención Primaria/métodos , Centros Médicos Académicos , Adulto , Distribución por Edad , Anciano , Índice de Masa Corporal , Estudios de Cohortes , Enfermedad Crítica/terapia , Femenino , Humanos , Incidencia , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Evaluación en Enfermería/métodos , Valor Predictivo de las Pruebas , Úlcera por Presión/enfermería , Úlcera por Presión/prevención & control , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Distribución por Sexo , Cuidados de la Piel/métodos , Estadísticas no Paramétricas , Cicatrización de Heridas/fisiologíaRESUMEN
Cervical collars are necessary to stabilize the cervical spine of trauma patients but are known to contribute to the development of occipital pressure ulcers. A quality improvement project that began on one nursing unit stimulated the development of evidence-based practice guidelines and a multidisciplinary research study. As a result, a standardized plan of care and cervical collar recommendations were implemented, resulting in a sharp decline in the incidence of occipital pressure ulcers.
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Tirantes/efectos adversos , Vértebras Cervicales/lesiones , Hueso Occipital , Úlcera por Presión/prevención & control , Gestión de la Calidad Total/organización & administración , Tirantes/provisión & distribución , Educación Continua en Enfermería , Diseño de Equipo , Medicina Basada en la Evidencia , Humanos , Inmovilización/efectos adversos , Inmovilización/instrumentación , Inmovilización/métodos , Incidencia , Difusión de la Información , Enfermeras Clínicas , Evaluación en Enfermería , Investigación en Evaluación de Enfermería , Personal de Enfermería en Hospital/educación , Planificación de Atención al Paciente , Grupo de Atención al Paciente , Guías de Práctica Clínica como Asunto , Úlcera por Presión/epidemiología , Úlcera por Presión/etiología , Factores de Riesgo , Cuidados de la Piel/métodos , Cuidados de la Piel/enfermería , Centros TraumatológicosRESUMEN
BACKGROUND: Occipital pressure ulcers are well-known complications for trauma patients wearing cervical collars. We assessed the effects of four commercial cervical collars (Aspen, Philadelphia, Miami J, and Miami J with Occian back [Miami J/Occian]) on cervical range of motion (CROM) and mandibular and occipital tissue-interface pressure (TIP). METHODS: Forty-eight healthy volunteers (24 men, 24 women; mean age, 38.9 years +/- 10.5 years) were stratified by body mass index. CROM was measured in the seated position without and with collars. Sagittal, coronal, and rotatory CROM was measured with a goniometer. Occipital and mandibular pressures were mapped with subjects in upright and supine positions. RESULTS: All collars significantly restricted CROM in all planes (p < 0.001). The Philadelphia and standard Miami J collars were the most restrictive. The Aspen collar was the least restrictive for flexion and rotation. The Miami J/Occian back was the least restrictive for extension and lateral flexion. For supine measurements, Miami J and Miami J/Occian back had the lowest mean TIP, whereas Aspen and Philadelphia collars had the greatest (p < 0.001). For upright measurements, the Miami J/Occian back produced the smallest mean TIPs; the other collars, ranked by ascending TIP, were Philadelphia, Miami J, and Aspen (p < 0.001). Philadelphia and Miami J collars had significant collar-body mass index interaction effects on supine occiput mean pressure (p = 0.04). CONCLUSIONS: Miami J and Philadelphia collars restricted CROM to the greatest extent. Miami J and Miami J/Occian back had the lowest levels of mandibular and occipital pressure; these collars may markedly reduce the risk of occipital pressure ulcers without compromising immobilization.
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Tirantes , Cuello/fisiología , Adulto , Tamaño Corporal/fisiología , Diseño de Equipo , Cara/fisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Postura , Presión , Estudios Prospectivos , Rango del Movimiento Articular , Cráneo/fisiologíaRESUMEN
BACKGROUND: Sustained hyperglycemia is a known risk factor for adverse outcomes in critically ill patients. The specific aim was to determine if a nurse initiated insulin infusion protocol (IIP) was effective in maintaining blood glucose values (BG) within a target goal of 100-150 mg/dL across different intensive care units (ICUs) and to describe glycemic control during the 48 hours after protocol discontinuation. METHODS: A descriptive, retrospective review of 366 patients having 28,192 blood glucose values in three intensive care units, Surgical Trauma Intensive Care Unit (STICU), Medical (MICU) and Coronary Care Unit (CCU) in a quaternary care hospital was conducted. Patients were > 15 years of age, admitted to STICU (n = 162), MICU (n = 110) or CCU (n = 94) over 8 months; October 2003-June 2004 and who had an initial blood glucose level > 150 mg/dL. We summarized the effectiveness and safety of a nurse initiated IIP, and compared these endpoints among STICU, MICU and CCU patients. RESULTS: The median blood glucose values (mg/dL) at initiation of insulin infusion protocol were lower in STICU (188; IQR, 162-217) than in MICU, (201; IQR, 170-268) and CCU (227; IQR, 178-313); p < 0.0001. Mean time to achieving a target glucose level (100-150 mg/dL) was similar between the three units: 4.6 hours in STICU, 4.7 hours in MICU and 4.9 hours in CCU (p = 0.27). Hypoglycemia (BG < 60 mg/dL) occurred in 7% of STICU, 5% of MICU, and 5% of CCU patients (p = 0.85). Protocol violations were uncommon in all three ICUs. Mean blood glucose 48 hours following IIP discontinuation was significantly different for each population: 142 mg/dL in STICU, 167 mg/dL in MICU, and 160 mg/dL in CCU (p < 0.0001). CONCLUSION: The safety and effectiveness of nurse initiated IIP was similar across different ICUs in our hospital. Marked variability in glucose control after the protocol discontinuation suggests the need for further research regarding glucose control in patients transitioning out of the ICU.