Capturing Original Preanesthetic Comprehensive History and Physical Assessments with the use of Video Telehealth: A Quality Improvement Project for Student Nurse Anesthetists

PURPOSE

Beginning January 1, 2022, the Council on Accreditation is requiring student registered nurse anesthetists (SRNAs) matriculating into nurse anesthesia programs to track preanesthetic comprehensive history and physical (H&P) assessment completion numbers. This quality improvement (QI) project aimed to create a new clinical rotation for SRNAs to practice their preanesthetic H&P assessment skills through video telehealth.

DESIGN

A quality improvement project.

METHODS

Likert-style and free-text surveys were administered to both the SRNA students and the expert provider to assess for improvements, viability, and effectiveness of the clinical rotation. SRNAs used a curated library of evidence-based resources and instructions for conducting their assessments. Expert guidance was provided through a single experienced provider.

FINDINGS

Eight SRNAs performed one preanesthetic telehealth H&P assessment and four of the eight performed a second assessment. Pre-QI surveys indicated 75% were not comfortable with their ability in performing a competent assessment. Initial post-QI surveys indicated 88% were more comfortable with their abilities and 100% of those who completed a second-time post-QI survey 100% were more comfortable. Provider feedback indicated full-day clinical rotations were feasible and important.

CONCLUSIONS

Results revealed SRNAs desire and need for more preanesthetic comprehensive H&P appointments. Expansion into full-scale, full-day, and in-person assessments was also indicated. QI projects at other clinical sites can determine if similar rotations can also create similar clinical rotations.

Safety and Acceptability of Patient-Administered Sedatives During Mechanical Ventilation

BACKGROUND

Safety and acceptability of sedative self-administration by patients receiving mechanical ventilation is unknown.

OBJECTIVES

To determine if self-administration of dexmedetomidine by patients is safe and acceptable for self-management of anxiety during ventilatory support.

METHODS

In a pilot trial in 3 intensive care units, 17 intubated patients were randomly assigned to dexmedetomidine and 20 to usual care. Dexmedetomidine was administered via standard pumps for patient-controlled analgesia, with a basal infusion (0.1-0.7 μg/kg per hour) titrated by the number of patient-triggered doses (0.25 μg/kg per dose). Safety goals were heart rate greater than 40/min, systolic blood pressure greater than 80 mm Hg, and diastolic blood pressure greater than 50 mm Hg. Acceptability was based on patients' self-reported satisfaction and ability to administer the sedative. A 100-mm visual analog scale was used daily to assess patients' anxiety.

RESULTS

The sample was 59% male and 89% white. Mean values were age, 50.6 years; score on the Acute Physiology and Chronic Health Evaluation, 60.1; and protocol duration, 3.4 days. Five dexmedetomidine patients had blood pressure and/or heart rate lower than safety parameters, necessitating short-term treatment. Nurses' adherence to reporting of safety parameters was 100%; adherence to the dexmedetomidine titration algorithm was 73%. Overall baseline anxiety score was 38.4 and did not change significantly (β_day = 2.1; SE, 2.5; P = .40). Most dexmedetomidine patients (92%) were satisfied or very satisfied with their ability to self-administer medication.

CONCLUSIONS

For select patients, self-administration of dexmedetomidine is safe and acceptable.

Perceptions of Patients and Families who Received a Music Intervention During Mechanical Ventilation

The intensive care unit (ICU) is a technologically-driven environment where critically ill patients and their families have significant physical and emotional experiences. Mechanically ventilated (MV) patients can experience significant distress from anxiety and pain. Music listening is one integrative intervention that has been shown to reduce anxiety as well as other symptoms that contribute to distress in MV patients. This is a report of MV patient and family experiences from a larger research study aiming to evaluate levels of anxiety and sedative exposure with use of a patient-directed music intervention. Understanding perceptions of MV patients and families regarding the effectiveness of music listening might serve as a useful guide to improvement of their care.

Achieving quality patient-ventilator management: advancing evidence-based nursing care

This article presents suggestions for nurses to gain skill, competence, and comfort in caring for critically ill patients receiving mechanical ventilatory support, with a specific focus on education strategies and building communication skills with these challenging nonverbal patients. Engaging in evidence-based practice projects at the unit level and participating in or leading research studies are key ways nurses can contribute to improving outcomes for patients receiving mechanical ventilation. Suggestions are offered for evidence-based practice projects and possible research studies to improve outcomes and advance the science in an effort to achieve quality patient-ventilator management in intensive care units.

Feasibility of a music intervention protocol for patients receiving mechanical ventilatory support

CONTEXT

Music has been found to be an effective nonpharmacologic adjunct for managing anxiety and promoting relaxation in limited trials of critically ill patients receiving mechanical ventilation. No data are available to determine the effect of the intervention over repeated trials or to determine whether patients or staff will use music intervention independently.

OBJECTIVE

To test the feasibility of a patient-initiated music intervention protocol over a 3-day trial and to discern the associated barriers to adherence by study participants and nursing staff.

DESIGN

Descriptive pilot study.

SETTING

Two adult critical care units contained in 1 university-affiliated tertiary care center in the urban Midwest.

PATIENTS

Five alert, critically ill adults receiving mechanical ventilatory support.

INTERVENTION

Patient-selected music listening via audiotapes and head-phones with frequency and length of session determined by each patient.

MAIN OUTCOME MEASURES

Anxiety, heart rate, respiratory rate, blood pressure, and identified barriers to protocol adherence.

RESULTS

Subjects averaged 2 self-initiated music interventions (mode = 3; range = 1-5) and listened for an average of 67.8 minutes per session (SD 34.3; mode = 50; range = 25-120 minutes). Barriers to this intervention included inaccessibility of the equipment and lack of knowledge and experience of the nursing staff. Due to missing data, physiological measures were not interpretable.

CONCLUSIONS

Patient-initiated music is a feasible intervention protocol: subjects were able to request music independently and nursing staff were cooperative. Findings will be used in future studies to refine the protocol and attendant measures to implement music intervention in the critical care setting and to develop detailed staff education materials.

Creating a collaborative environment to care for complex patients and families

Today's critical care environment is increasingly complex due to technological advancements, greater intensity of interventions, and a myriad of healthcare providers. Critically ill patients and their families can feel overwhelmed with the stress of the environment in addition to the acute illness. This stress affects the patients' and families' ability to function, cope, and understand complex information. For some families, this experience precipitates distrustful relationships with care providers. The resulting impact on quality of care, staff morale, length of stay, and cost is high. The purpose of this article is to describe issues encountered by one medical center in caring for complex patients and families. A representative case outlines the types of issues the staff in the adult intensive care units faced. Use of a comprehensive problem-solving model to address concerns resulted in structured approaches to guide healthcare providers in caring for complex patients and families. The goal of these approaches was to support all parties involved in the care of complex patients, improve communication, and avoid crises that resulted from distrustful relationships and lack of skill in resolving conflict.

Music therapy in critical care: indications and guidelines for intervention

Music therapy is an effective intervention for critically ill patients for such purposes as anxiety reduction and stress management. The therapy is readily accepted by patients and is an intervention patients thoroughly enjoy. The MAIT is one resource that nurses caring for critically ill patients can use to implement music therapy in clinical practice. Patients can be given the opportunity to select a musical tape they prefer and to negotiate with the nurse for uninterrupted music-listening periods. Allowing patients control over music selection and providing uninterrupted time for music listening gives the patients an enhanced sense of control in an environment that often controls them.

Music therapy in critical care: indications and guidelines for intervention

Music therapy is an effective intervention for critically ill patients for such purposes as anxiety reduction and stress management. The therapy is readily accepted by patients and is an intervention patients thoroughly enjoy. The MAIT is one resource that nurses caring for critically ill patients can use to implement music therapy in clinical practice. Patients can be given the opportunity to select a musical tape they prefer and to negotiate with the nurse for uninterrupted music-listening periods. Allowing patients control over music selection and providing uninterrupted time for music listening gives the patients an enhanced sense of control in an environment that often controls them.

Force exertion in awkward working postures--strength capability while twisting or working overhead

Isometric strength data have been collected for three of the awkward work situations often imposed by workplace constraints in industry, as found in jobs such as maintenance and repair. The effects of the task layout factors (location of the workpiece, reach distance and direction of force exertion) were investigated and the data has been tabulated to show the degree to which strength may be reduced in different situations. Strength measurements in the present study were found to be considerably higher than previous measurements, apparently due to differences in instructions on foot placement that were given to subjects, which indicates that even small constraints on posture within the workplace may have large effects on the ability to exert force.

Strength capability while kneeling

Work sometimes has to be carried out kneeling, particularly where jobs are performed in confined spaces as is common for miners, aircraft baggage handlers and maintenance workers. In order to assess the risks in performing forceful tasks under such conditions, data is needed on strength capabilities of kneeling subjects. A study was undertaken to measure isometric strength in single-handed exertions for male subjects and to investigate the effects on this of task layout factors (direction of force exertion, reach distance, height of the workpiece and orientation relative to the subject's sagittal plane). The data has been tabulated to show the degree to which strength may be reduced in different situations and analysis of the task factors showed their influence to be complex with direction of exertion and reach distance having the greatest effect. The results also suggest that exertions are weaker when subjects are kneeling on two knees than when kneeling on one knee, although this needs to be confirmed by direct experimental comparison.

Peer review of nursing research proposals

The grant review process that operationalizes peer review for the critique, scoring, approval, and selection of research grants for funding may intimidate a novice reviewer. This article describes the peer review panel and process of grant review, specifies the role and responsibilities of the reviewer in the review session, and presents considerations for the evaluation of proposals and the preparation of a written critique. A sample critique is provided.

Peer review of nursing research proposals

The grant review process that operationalizes peer review for the critique, scoring, approval, and selection of research grants for funding may intimidate a novice reviewer. This article describes the peer review panel and process of grant review, specifies the role and responsibilities of the reviewer in the review session, and presents considerations for the evaluation of proposals and the preparation of a written critique. A sample critique is provided.

Overcoming the obstacles to research-based clinical practice

The utilization of research findings in the practice of critical care nursing is essential to obtain optimal patient outcomes. However, the speed and extent to which new research-based findings are applied to clinical practice falls short of expectations. The authors identify obstacles to the timely utilization of research. Strategies to overcome the obstacles to research-based clinical practice are presented.

Developing nursing guidelines for the PTCA patient

Developing guidelines for the care of complicated patients is not an easy task. This article describes how a group of critical care nurses produced guidelines for the nursing care of patients undergoing percutaneous transluminal coronary angioplasty (PTCA). Guidelines are important in guiding nursing actions without the legal restrictions implicit in using standards.

Loads on the body during static tasks: software incorporating the posture targetting method

The biomechanical evaluation of loads on the body is one of the tools that facilitate the assessment of manual handling tasks. A computer program has been developed to determine moments about joints during static tasks. It differentiates between flexion/ extension, rotation and adduction/abduction requirements so that the major efforts can be identified and compared with population strength data. It also evaluates loads on the spine and within low-back muscles for purposes of comparison with many manual handling studies. Posture and a variety of external forces are input to the system with a choice of two interchangeable methods: one uses a 'CODA' scanner for on-line posture recording in the laboratory, the other is 'posture targetting', a pen-and-paper method adapted for the computer.

A biomechanical manikin for the evaluation of loads on the body

A simple tool to evaluate loads at body joints is described. Its function is to analyse static tasks performed in the sagittal plane. It consists of an articulated plastic manikin placed in the required posture on a magnetic board. The manikin has a set of scales which indicate moments of forces around the elbow, shoulder, lumbosacral or knee joints generated by any force exertion. The readings take into account several percentiles of stature and body weight and any value and direction of force applied in the task. A graph also provides an estimate of the intervertebral compression forces.

Three-dimensional force model of the low-back for simple computer programming

A three-dimensional static model is described to evaluate the forces on low-back muscles and on the spine during manual handling tasks and other forceful activities. It is simple to use either with a calculator or programmed onto a micro-computer, whilst being more accurate than existing simple models. Comparisons are made with a more sophisticated model that requires mathematical libraries and programming skills. As predictions are similar, so is the area of validity: the proposed model's accuracy is good for light tasks but poorer for strenuous ones.

The geometry of the muscles of the lumbar spine determined by magnetic resonance imaging

Magnetic Resonance Imaging (MRI) is a new multiplanar imaging technique that clearly demonstrates soft tissue anatomy. The lumbar spines of 26 males have been scanned. From the transverse scans, the position and cross-sectional areas of the muscles of the lumbar region were recorded. Regression analysis was performed to relate these values to trunk measurements and body weight. Sagittal scans were used to measure the angles to the vertical of the lumbar discs and of the skin overlying the spinous processes. The position of each lumbar disc relative to two skin points was measured. These parameters can then be used in biochemical calculations of low-back forces.