A human factors approach to evaluate predicators of acute care nurse occupational fatigue

Nurses function at the point of care and assume a significant role in intercepting errors. They work in a mentally and physically demanding profession that is comprised of shift-work, subjecting nurses to considerable fatigue. Yet, few studies constructed a comprehensive model that integrates personal and occupational factors to explore their relationship with various types of fatigue (acute, chronic, physical, mental, and total). Here, we examine this type of comprehensive fatigue-model, in a report that represents one aim of a larger, mixed-methods study. The study sample comprised of 1137 registered nurses working in eight hospitals in a Midwestern state. Nurses reported higher levels of acute and total fatigue than chronic and physical fatigue. Staffing and resource adequacy, exercise, and sleep were among the strongest predictors. Since fatigue is a multi-faceted construct, a comprehensive fatigue-management strategy that targets both day and night-shift nurses is the optimal way to manage nurse fatigue.

In vivo analysis of mucosal lipids reveals histological disease activity in ulcerative colitis using endoscope-coupled Raman spectroscopy

The goal of this study is to evaluate endoscopic Raman spectroscopy as a noninvasive technique to determine histological inflammatory status of colitis. Colon mucosal composition was investigated in vivo from patients with ulcerative colitis (UC) and from age- and body mass index (BMI) matched controls using endoscope-coupled Raman spectroscopy. The results were co-registered with histological assessment of inflammatory status at the same locations. Substantial decreases (50-60%) in the content of phosphotidylcholines (PCs) and total lipids were observed in inflamed colon tissue (histology grade 1, 2 and 3) compared to those from the quiescent (histology grade 0) and from the controls. No significant difference was observed in lipids or PC contents between control and grade 0, or among grades 1 - 3. The degree of lipid unsaturation increased in the inflamed tissue regardless of disease severity. The inflammation-associated alterations in lipids and PC are observed independent of BMI or the anatomical locations for data collection. Multivariate analysis using support vector machine (SVM) algorithm classified the spectra of the controls or the inactive colitis from those of inflamed tissue with a sensitivity of 83.5% and 97.1% respectively. Our results showed that mucosal lipid content is related to the microscopic disease activity, and thus could serve as a valuable spectral marker to differentiate active colitis from the quiescent.

Abstract B78: Using the Quality in the Continuum of Cancer Care framework to develop a multilevel intervention to improve cancer screening and follow-up among the medically underserved

Introduction: Screening for cervical, colorectal, and breast cancer is an evidence-based strategy to reduce the morbidity and mortality from these cancers. However a large proportion of medically underserved individuals do not obtain regular screening. Using the Quality in the Continuum of Cancer Care (QCCC) framework, we developed and implemented a comprehensive systems design intervention to improve the delivery, uptake, and follow-up of cervical, colorectal, and breast cancer screening within a network of healthcare institutions that serve the medically underserved in Harris County, Texas.

Methods: An academic-community partnership, the Community Network for Cancer Prevention, was established between an academic cancer center, the county's safety net healthcare system, and several academic and community-based healthcare institutions. Clinical advisory boards, comprised of physicians, nurses, and public health professionals, were established for each cancer line. The QCCC framework was used to identify system-level failures that impede processes and transitions in the continuum of care from risk assessment to detection and from detection to diagnosis. Project components were developed to address the identified failures.

Results: System failures identified at the risk assessment to detection phases included 1) failure to identify individuals in need of screening, 2) inadequate capacity to screen, and 3) inadequate access to care. Failures identified at the detection to diagnosis phases included 1) failures in the screening test results notification system, 2) failures in inter-provider communication, 3) failures in inter-institutional referrals for clinical follow-up, 4) patient non-adherence, and 5) inadequate access to care. Project components to address the identified failures include community outreach, patient education, and patient navigation. Community outreach involves a community theater program aimed to increase awareness of cancer risk and the current cancer screening guidelines among medically underserved individuals in the larger community; healthcare access navigators available at each performance assist audience members in applying for healthcare coverage through the safety net healthcare system. Patient education involves using the electronic medical record to identify patients due or past due for cervical, colorectal, and/or breast cancer screening. These patients are then targeted for a video-based patient education intervention while they wait to be seen by their healthcare provider. Motivational messaging in the videos encourages patients to discuss the particular screening test with their provider. Finally, patient navigation involves a team of navigators who actively communicate with patients and providers to ensure follow-up among patients with an abnormal screening test result. A real-time tracking database is used to monitor all screen-test positive patients as they move through the different stages of diagnostic and therapeutic follow-up.

Conclusion: The QCCC provides a systematic approach for assessing factors that influence cancer care processes at the risk assessment, screening, detection, and diagnosis phases, as well as transitions between them. Focusing on transitions between phases is particularly useful for developing systems-level interventions to improve the delivery, uptake, and follow-up of cancer screening.

Citation Format: Jane R. Montealegre, Loretta Hanser, Maria Daheri, Roshanda Chenier, Ivan Valverde, Glori S. Chauca, Luis O. Rustveld, Matthew L. Anderson, Lois Ramondetta, Milena Gould-Suarez, Musher L. Benjamin, Larry D. Scott, Juli R. Nangia, Brian C. Reed, Janet Hoagland-Sorensen, Alyssa Rieber, Maria L. Jibaja-Weiss. Using the Quality in the Continuum of Cancer Care framework to develop a multilevel intervention to improve cancer screening and follow-up among the medically underserved. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B78.

Gastritis cystica profunda: Endoscopic ultrasound findings and review of the literature

Gastritis cystica profunda (GCP) is a rare pseudotumor of the stomach characterized by benign growths of deep gastric glands through the muscularis mucosae into the submucosa. We review a case of GCP in a 61-year-old patient with GCP, with emphasis on endoscopic ultrasound findings and present review of the current literature.

Artificial nutrition and hydration: the evolution of ethics, evidence, and policy

INTRODUCTION

The debate over use of artificial nutrition and hydration (ANH) in terminal illness, including advanced dementia, remains contentious despite extensive ethical and empirical investigation.

METHODS

For this narrative review we undertook a focused, selective review of literature reflecting ethical analysis, empirical assessment of outcomes, legal responses, and thinking within the Roman Catholic religious tradition.

RESULTS

The history of the debate over the past 60 years results from a complex interplay of ethical concerns, a growing empirical database, legal changes, public opinion, and financial as well as institutional concerns. Discussions of ANH today are often conducted without any understanding of this historical context.

DISCUSSION

Patients' interests could be better protected through remedial action at both the individual and the policy levels.

Role of registered nurses in error prevention, discovery and correction

BACKGROUND

Registered nurses have a vital role in discovering and correcting medical error.

OBJECTIVE

To describe the type and frequency of errors detected by American critical care nurses, and to ascertain who made the errors discovered by study participants.

METHODS

Daily logbooks were used to collect information about errors discovered by a random sample of 502 critical care nurses during a 28-day period.

RESULTS

Although the majority of errors discovered and corrected by critical care nurses involved medications (163/367), procedural errors were common (n = 115). Charting and transcription errors were less frequently discovered. The errors discovered by participants were attributed to a wide variety of staff members including nurses, doctors, pharmacists, technicians and unit secretaries.

CONCLUSIONS

Given the importance of nurses in maintaining patient safety, future studies should identify factors that enhance their effectiveness to prevent, intercept and correct healthcare errors.

Research-related injury: problems and solutions

The highly publicized deaths of research participants Ellen Roche and Jesse Gelsinger are stark reminders that risk is inherent in medical research and while untoward outcomes are infrequent when compared to individual and societal benefits, injury and even death will happen. Who is responsible for the welfare of research subjects and what are they owed? Why were they put at risk to begin with? Are obligations, if any, to research subjects dependent on the type of study in which they participate, in recognition that there may be personal benefit from participation in some studies?

The issue of injury resulting from participation in research and answers to questions such as those just posed were last considered in depth nearly 20 years ago by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.

The similarities and differences of endometritis and pelvic inflammatory disease

Pelvic inflammatory disease, a common gynecologic problem with an estimated 1 million cases annually, results in serious sequelae. Endometritis, a common obstetric problem occurring in more than 15% of all pregnancies, is the leading cause of maternal mortality. Risk factors are numerous. Diagnosis is not always definitive and relies heavily on the clinical judgment of the practitioner. Prompt initiation of empiric treatment regimens, close monitoring of the client, and client education result in positive health outcomes.

Caregiving and care receiving among a technologically dependent heart failure population

This descriptive study investigated health-related quality of life (HRQOL) and caregiving/care receiving among 20 end stage heart failure patients receiving community-based inotropic infusions and among their 18 family caregivers. The analysis revealed that care recipients perceived considerable impairment from their disease process and poor HRQOL despite the use of inotropic infusions. Perceived powerlessness was identified as a predictor of the recipients' mental health status, while caregiver esteem adversely affected recipient HRQOL. Although insufficient preparation to care and caregiving tasks significantly contributed to the negative aspects of care provision. the esteem and mental health of the caregiver significantly enhanced HRQOL among caregivers.

Evaluation of advanced cardiac life support written examinations

OBJECTIVE

To examine the quality of 2 advanced cardiac life support written examinations and the relationship between demographic variables and test performance.

DESIGN

Descriptive.

SETTING

Advanced cardiac life support courses held at 4 midwestern hospitals, one outpatient surgery center, and one community college.

SUBJECTS

Nonprobability sample of 367 participants.

OUTCOME MEASURE

Two versions of the American Heart Association advanced cardiac life support written examinations.

RESULTS

Reliability coefficients of test A and test B were 0.45 and 0.54, respectively. Discrimination and difficulty indices calculated on both tests revealed that test B questions were more difficult, with better discriminators. Prior experience, sex of participant, and profession were identified as factors influencing test performance.

CONCLUSION

Although test B surpassed the performance of test A, both examinations were problematic. Additional investigation and refinement of the advanced cardiac life support tests are warranted.

Perceived needs of parents of critically ill children

PURPOSE

To identify the needs of parents of critically ill hospitalized children as perceived by the parents and critical care nurses, and to identify any differences between the two groups.

DESIGN

Descriptive, comparative.

SETTING

Pediatric intensive care unit (PICU) in a Midwestern hospital.

PARTICIPANTS

A nonprobability convenience sample of parents or primary caregivers of critically ill children (n = 21) and pediatric critical care nurses (n = 17).

OUTCOME MEASURES

Critical Care Family Needs Inventory modified for pediatrics and demographic questionnaires.

RESULTS

Information, assurance, and proximity to the critically ill child were identified as priority needs of the PCGs in this study. Significant differences on specific needs were identified between PCG/nurse matched pairs; however, no significant differences were found in total scores between the two groups by a two-tailed paired t test.

CONCLUSIONS

This study supports the need to investigate interventions to better address parental needs of critically ill children. By consistent identification, prioritization, and incorporation of parental needs into the plan of care, nurses can assist the parents in the recognition and fulfillment of needs that have less perceived importance. Research-based interventions will facilitate improved parental adaptation to their child's critical hospitalization.

Nurse consultant and professional liability

The expanded role of nurse consultant brings greater responsibility and risk of professional liability in a litigious society. The nurse consultant needs to be aware of the elements that constitute malpractice and be able to plan for the management of risks involved. When purchasing a liability policy, the nurse consultant must consider the practice setting, types of policies, components of the policy, cost, and means to obtain adequate coverage. Other strategies for protection include proper use of the consultant process, client communication, and individualized client contracts. A well-written contract serves as a legal document to delineate responsibilities and outcomes, provide a professional image, and protect against possible negative developments.

Gallstone disease and pancreatitis in pregnancy

Controversy exists over whether pregnancy is a risk factor for gallstone formation; however, changes in hepatobiliary function do occur during pregnancy to create a lithogenic environment; these changes include gallbladder stasis and secretion of bile with increased amounts of cholesterol and decreased amounts of chenodeoxycholic acid. In women with existing gallstones, pregnancy may bring out symptoms, including pain and even acute cholecystitis. This may be more common during the postpartum period than during pregnancy itself; however, the overall occurrence of symptomatic biliary disease in association with pregnancy is low. The effects of pregnancy, if any, on pancreatic exocrine function are undefined. Acute pancreatitis can occur during pregnancy but does not appear to do so with either increased or, alternatively, decreased frequency. The concept of pancreatitis caused by pregnancy per se is not valid, although in susceptible women with lipid disorders, hypertriglyceridemia can occur and serve as an etiologic factor. Gallstones are a common cause of pancreatitis, but in contrast to nonpregnant women, alcohol is unusual as a cause. Although the presentation of both acute cholecystitis and acute pancreatitis may be similar to that in the nonpregnant state, the differential diagnosis of both these disorders is expanded because of unique pregnancy-related conditions and the shift of abdominal viscera by the enlarging uterus. The diagnosis is clinical and supported with conventional laboratory studies and ultrasound; management is supportive and in most patients successful. Cholecystectomy is seldom necessary during pregnancy, either for acute cholecystitis or gallstone pancreatitis, but can be safely performed if necessary after the first trimester. Endoscopic papillotomy and stone removal for choledocholithiasis are possible during pregnancy and may be the treatment of choice for this unusual condition. Specific enteral or parenteral nutrition may be necessary in women with pancreatitis associated with hypertriglyceridemia.

Esophageal adenocarcinoma in a patient with surgically treated achalasia

Although squamous cell carcinoma of the esophagus occurs with increased incidence in primary achalasia, esophageal adenocarcinoma has been considered rare in this condition. We report a patient with long-standing achalasia in whom adenocarcinoma of the esophagus occurred many years after Heller esophagomyotomy, presumably related to Barrett's esophagus complicating gastro-esophageal reflux disease.

Cholinergic responsiveness of intestinal muscle in the pregnant guinea pig

Clinical observations and limited animal experiments have suggested that gastrointestinal motility is suppressed during pregnancy. We therefore compared isometric contractions of colon and ileal circular muscle in response to carbachol (10(-8) to 10(-4) M). Data was analyzed by comparing mean maximal tension, dose-response curves, and EC50 values for tissue from the two groups of animals. Circular muscle from proximal colon, distal colon, and ileum in pregnant animals developed less tension in response to carbachol than did tissue from non-pregnant controls. Dose-response curves in the pregnant groups were depressed, when compared with non-pregnant groups, at concentrations of 10(-6) M and greater. Sensitivity of the muscle to cholinergic stimulation, as measured by EC50 values, was similar in the ileum and proximal colon but increased slightly (p less than 0.05), by a factor of approximately 2, for distal colonic muscle from pregnant animals. Assuming that circular muscle contractions are primarily responsible for mixing and propulsion in the gut, this reduction in responsiveness to excitatory cholinergic stimulation is consistent with the concept of pregnancy-related suppression of gastrointestinal motility.

Evaluation of esophageal diseases

The diagnosis of esophageal disease can be made by history alone in 80 percent of patients. Primary symptoms include dysphagia, odynophagia, heartburn and central chest pain. Although these symptoms may overlap, one esophageal symptom often predominates. This observation and an understanding of the available diagnostic tests enable the clinician to develop an algorithmic approach to the diagnosis of esophageal diseases.

Oral contraceptives, pregnancy, and focal nodular hyperplasia of the liver

There is uncertainty regarding the role, if any, of oral contraceptive steroids in the development of focal nodular hyperplasia of the liver. In a 36-year-old woman, a large left hepatic lobe tumor developed that was detected after 11 years of using these drugs. The tumor regressed when administration of the drug was stopped but began to increase in size during a subsequent pregnancy. A left hepatic lobectomy during the second trimester disclosed focal nodular hyperplasia. Both contraceptive steroids and pregnancy, with high levels of endogenous sex steroids, favored tumor growth in this patient, suggesting that focal nodular hyperplasia can be steroid related.

Esophageal obstruction caused by mediastinal histoplasmosis: beneficial results of operation

A patient presented with progressive dysphagia and chest pain. Radiologic investigation showed extrinsic compression of the esophagus by enlarged, calcified, mediastinal lymph nodes. Immunologic studies suggested that this was due to previous histoplasmosis, currently inactive. The nodes were excised at thoracotomy, with complete relief of symptoms. Operative management was most appropriate because of the apparent inactivity of the infection, the severity and progressive nature of the symptoms, and the possible prophylaxis of mediastinal fibrosis, a well-documented complication of histoplasmosis.

Pregnancy-related changes in small intestinal myoelectric activity in the rat

To determine if changes in intestinal motility occur during pregnancy, we studied small intestinal myoelectric activity, using monopolar electrodes, in fasted pregnant rats from day 12 to day 18 of the 22-day gestation period. We also studied fasting myoelectric activity in postpartum, nonpregnant, and castrate females. In all rats, the interdigestive myoelectric complex was invariably present with recurring activity fronts appearing at the proximal electrode and moving slowly abroad. Intervals between fronts were similar in all four groups, ranging from 12.61 min to 14.58 min. In pregnant rats, however, there was loss of the periodicity characteristic of activity fronts in the other groups; intervals up to 43 min in length were occasionally noted. Unorganized, randomly occurring spike potentials characterized these intervals. The average coefficient of variation of interval length was significantly (p less than 0.05) greater in pregnant rats (0.401) than in castrate (0.197) and nonpregnant rats (0.248). These studies confirm the presence in rats of pregnancy-related changes in small intestinal myoelectric activity.

Influence of the interdigestive myoelectric complex on enteric flora in the rat

This study was designed to define the role of the interdigestive myoelectric complex in small intestinal bacteriostasis. In rats, six monopolar electrodes were surgically sewn to the small intestine at equal intervals. One week later myoelectric activity was recorded. Under different experimental conditions, segments of duodenum and ileum were cultured quantitatively, both aerobically and anaerobically. Five groups of 6 electrode-equipped animals each were studied after an overnight fast: rats in which (a) the interdigestive myoelectric complex was present, (b) the interdigestive myoelectric complex was disrupted for 6 h using morphine sulfate, (c) the interdigestive myoelectric complex was disrupted for 15 h using morphine sulfate, (d) the interdigestive myoelectric complex was disrupted for 15 h using phenylephrine, and (e) the interdigestive myoelectric complex returned after 15 h of morphine sulfate effect. In control rats and during baseline records before drug administration in the other four groups, the interdigestive myoelectric complex was present. Activity fronts cycled at regular intervals in the proximal small intestine and moved aborally. Activity fronts disappeared following both morphine and phenylephrine, with varying degrees of inhibition of spike activity. Titers of microorganisms increased after 6 h, becoming statistically significant at 15 h; this effect was seen with both drugs. However, titers were similar to controls in groups 5. These results show that the interdigestive myoelectric complex is an important regulator at bacterial growth in the small intestine.