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Category: Nursing

A study presented at Euroanaesthesia 2016 shows that noise levels in the Intensive Care Unit (ICU) can go well above recommended levels, disturbing both patients and the medical teams that care for them. The study is by Dr Eveline Claes, Jessa Ziekenhuis Hospital, Hasselt, Belgium and colleagues.

Noise exposure in the intensive care unit can have a negative impact on patients’ well-being as well as on optimal functioning of both nursing and medical staff. WHO recommends average sound levels for hospital wards below 35 decibels (dBA) with a maximum of 40 dBA at night time. Reported sound levels in ICUs are significantly higher with average sound levels always exceeding 45 dBA and for 50% of the time exceeding 52 dBA. After several patient complaints and remarks from the nursing staff as well as the medical staff about noise, the study authors wanted to assess a potential noise problem by measuring sound levels in one ward (12 beds) of their hospital’s ICU (Jessa Hospital).

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Authors: Garrouste-Orgeas, Maité MD; Max, Adeline MD; Lerin, Talia RP; Grégoire, Charles MD; Ruckly, Stéphane MSc; Kloeckner, Martin MD; Brochon, Sandie RN; Pichot, Emmanuelle RN; Simons, Clara RN; El-Mhadri, Myriame RN; Bruel, Cédric MD; Philippart, François MD, PhD; Fournier, Julien MSc; Tiercelet, Kelly MSc; Timsit, Jean-François MD, PhD; Misset, Benoit MD

Reference: Crit Care Med. 2016 Jun;44(6):1116-28.

To investigate family perceptions of having a nurse participating in family conferences and to assess the psychologic well being of the same families after ICU discharge.

Mixed-method design with a qualitative study embedded in a single-center randomized study.

Twelve-bed medical-surgical ICU in a 460-bed tertiary hospital.

One family member for each consecutive patient who received more than 48 hours of mechanical ventilation in the ICU.

Planned proactive participation of a nurse in family conferences led by a physician. In the control group, conferences were led by a physician without a nurse.

Of the 172 eligible family members, 100 (60.2%) were randomized; among them, 88 underwent semistructured interviews at ICU discharge and 86 completed the Peritraumatic Dissociative Experiences Questionnaire at ICU discharge and then the Hospital Anxiety Depression Questionnaire and the Impact of Event Scale (for posttraumatic stress-related symptoms) 3 months later. The intervention and control groups were not significantly different regarding the prevalence of posttraumatic stress-related symptoms (52.3 vs 50%, respectively; p = 0.83). Anxiety and depression subscale scores were significantly lower in the intervention group. The qualitative data indicated that the families valued the principle of the conference itself. Perceptions of nurse participation clustered into four main themes: trust that ICU teamwork was effective (50/88; 56.8%), trust that care was centered on the patient (33/88; 37.5%), trust in effective dissemination of information (15/88; 17%), and trust that every effort was made to relieve anxiety in family members (12/88; 13.6%).

Families valued the conferences themselves and valued the proactive participation of a nurse. These positive perceptions were associated with significant anxiety or depression subscale scores but not with changes in posttraumatic stress-related symptoms.

Authors: van der Zanden V, Beishuizen SJ, Scholtens RM, de Jonghe A, de Rooij SE, van Munster BC.

Reference: NCBINCBI Logo Skip to main content Skip to navigation Resources How To About NCBI Accesskeys babindMy NCBISign Out PubMed US National Library of Medicine National Institutes of Health Search databaseSearch term Search AdvancedHelp Result Filters AbstractSend to: J Am Med Dir Assoc. 2016 May 24. pii: S1525-8610(16)30093-7

Both anemia and blood transfusion could be precipitating factors for delirium; hence in postoperative patients with anemia at high risk for delirium, it is controversial whether transfusion is the best option. The aim of this study is to investigate the association of anemia and delirium and the role of blood transfusion within the multicomponent prevention strategy of delirium.

We conducted a substudy of a multicenter randomized controlled trial. Four hundred fifteen patients aged 65 to 102 years old admitted for hip fracture surgery were enrolled. Delirium was assessed daily using criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Data on hemoglobin values and transfusion were collected from the electronic medical records.

One hundred fifteen (32.5%) patients experienced delirium during hospitalization, 238 (57.5%) had a hemoglobin level ≤ 6.0 mmol/L (9.7 g/dL) at any time during hospitalization, and 140 (33.7%) received a blood transfusion. Anemia (a hemoglobin level ≤ 6.0 mmol/L [9.7 g/dL]) was associated with delirium (odds ratio, 1.81; 95% confidence interval, 1.15-2.86). Blood transfusion was a protective factor for delirium in patients with the lowest measured hemoglobin level ≤ 6.0 mmol/L (9.7 g/dL) (odds ratio, 0.26; 95% confidence interval, 0.10-0.70).

Low hemoglobin level is associated with delirium, and receiving a blood transfusion is associated with a lower delirium incidence. It would be interesting to investigate the effect of blood transfusion as part of the multicomponent treatment of delirium in patients with anemia.

Authors: John H. Alexander, M.D., M.H.S., and Peter K. Smith, M.D.

Reference: N Engl J Med 2016; 374:1954-1964

Coronary-artery bypass grafting (CABG) is very commonly performed. CABG improves survival among patients with multivessel coronary disease; those with more severe coronary disease, diabetes, or left ventricular dysfunction are especially likely to benefit.

Medical mistakes — from surgical disasters to accidental drug overdoses — are the No. 3 cause of death in the U.S., behind cancer and heart disease, two experts argued Wednesday.

They said a careful count of all deaths from preventable medical errors shows between 200,000 and 400,000 people a year die in the U.S. from these mistakes. The only way to get the country to do something about them is to start counting them, Dr. Martin Makary and Michael Daniel of Johns Hopkins University medical school argued.

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Authors: M.B. Leon

Aortic-Valve Replacement
Transcatheter aortic-valve replacement is a less invasive alternative to open surgery for high-risk patients with severe aortic stenosis. Could TAVR criteria be expanded to include patients at low or intermediate risk? New research findings are summarized in a short video.

Authors: Martin A Makary, professor , Michael Daniel, research fellow

Reference: BMJ 2016;353:i2139


Medical error is not included on death certificates or in rankings of cause of death. Martin Makary and Michael Daniel assess its contribution to mortality and call for better reporting

The annual list of the most common causes of death in the United States, compiled by the Centers for Disease Control and Prevention (CDC), informs public awareness and national research priorities each year. The list is created using death certificates filled out by physicians, funeral directors, medical examiners, and coroners. However, a major limitation of the death certificate is that it relies on assigning an International Classification of Disease (ICD) code to the cause of death.1 As a result, causes of death not associated with an ICD code, such as human and system factors, are not captured. The science of safety has matured to describe how communication breakdowns, diagnostic errors, poor judgment, and inadequate skill can directly result in patient harm and death. We analyzed the scientific literature on medical error to identify its contribution to US deaths in relation to causes listed by the CDC.2
Listen to interview

Authors: Scales DC, Fischer HD, Li P, Bierman AS, Fernandes O, Mamdani M, Rochon P, Urbach DR, Bell CM.

Reference: J Gen Intern Med. 2016 Feb;31(2):196-202

Patients are vulnerable to medication-related errors during transitions in care. Patients discharged from acute care hospitals may be at an elevated risk for the unintentional continuation of medications prescribed to prevent or treat complications that are associated with acute illness but are no longer indicated. We sought to evaluate rates of (primary objective) and risk factors for (secondary objective) potentially unintentional medication continuation following hospitalization.

A population-based cohort study of more than one million patients 66 years of age or older who were hospitalized in Ontario, Canada, between 2003 and 2011 and followed for 1 year (2004 to 2012). We created distinct cohorts by identifying seniors not previously receiving four classes of medications typically used to treat or prevent complications of acute illness: (1) antipsychotic medications, (2) gastric acid suppressants (histamine-2 blockers and proton pump inhibitors), (3) benzodiazepines, and (4) inhaled bronchodilators and steroids. After excluding documented indications, we followed patients to ascertain whether these medications were continued after hospital discharge, and assessed risk factors for their continuation using generalized estimating equations. The primary outcome was the new dispensation of any of the selected medications within 7 days of hospital discharge.

Prescription without documented indication occurred across all medication classes, from 12,209 patients (1.4 %) for antipsychotic medications to 34,140 patients (6.1 %) for gastric acid suppressants. Risk factors for unintentional continuation varied across medication groups, but rates were consistently higher for older patients, those with multiple comorbidities, and emergency hospitalizations. The largest absolute risk factor across all medications was a hospitalization > 7 days [OR 2.03 (95 % CI 1.94-2.11) for respiratory inhalers, 6.35 (95 % CI 5.91-6.82) for antipsychotic medications]. These medications were often continued at 1 year of follow-up, and accounted for a total additional medication cost of over CAD$18 million for the study population.

Discharged patients are at risk of being prescribed and dispensed medications that are typically intended to prevent or treat complications of acute illness, despite having no documented indication for chronic use.

aged; cohort studies; continuity of patient care; hospitalizations; medication errors; polypharmacy; prescriptions

Authors: Oczkowski SJ, Chung HO, Hanvey L, Mbuagbaw L, You JJ.

Reference: Crit Care. 2016 Apr 9;20(1):97.

For many patients admitted to the intensive care unit (ICU), preferences for end-of-life care are unknown, and clinicians and substitute decision-makers are required to make decisions about the goals of care on their behalf. We conducted a systematic review to determine the effect of structured communication tools for end-of-life decision-making, compared to usual care, upon the number of documented goals of care discussions, documented code status, and decisions to withdraw life-sustaining treatments, in adult patients admitted to the ICU.

We searched multiple databases including MEDLINE, Embase, CINAHL, ERIC, and Cochrane from database inception until July 2014. Two reviewers independently screened articles, assessed eligibility, verified data extraction, and assessed risk of bias using the tool described by the Cochrane Collaboration and the Newcastle Ottawa Scale. Pooled estimates of effect (relative risk, standardized mean difference, or mean difference), were calculated where sufficient data existed. GRADE was used to evaluate the overall quality of evidence for each outcome.

We screened 5785 abstracts and reviewed the full text of 424 articles, finding 168 eligible articles, including 19 studies in the ICU setting. The use of communication tools increased documentation of goals-of-care discussions (RR 3.47, 95 % CI 1.55, 7.75, p = 0.020, very low-quality evidence), but did not have an effect on code status documentation (RR 1.03, 95 % CI 0.96, 1.10, p = 0.540, low-quality evidence) or decisions to withdraw or withhold life-sustaining treatments (RR 0.98, 95 % CI 0.89, 1.08, p = 0.70, low-quality evidence). The use of such tools was associated with a decrease in multiple measures of health care resource utilization, including duration of mechanical ventilation (MD -1.9 days, 95 % CI -3.26, -0.54, p = 0.006, very low-quality evidence), length of ICU stay (MD -1.11 days, 95 % CI -2.18, -0.03, p = 0.04, very low-quality evidence), and health care costs (SMD -0.32, 95 % CI -0.5, -0.15, p

Authors: Cooper Z, Koritsanszky LA, Cauley CE, Frydman JL, Bernacki RE, Mosenthal AC, Gawande AA, Block SD.

Reference: Ann Surg. 2016 Jan;263(1):1-6.

To address the need for improved communication practices to facilitate goal-concordant care in seriously ill, older patients with surgical emergencies.

Improved communication is increasingly recognized as a central element in providing goal-concordant care and reducing health care utilization and costs among seriously ill older patients. Given high rates of surgery in the last weeks of life, high risk of poor outcomes after emergency operations in these patients, and barriers to quality communication in the acute setting, we sought to create a framework to support surgeons in communicating with seriously ill, older patients with surgical emergencies.

An interdisciplinary panel of 23 national leaders was convened for a 1-day conference at Harvard Medical School to provide input on concept, content, format, and usability of a communication framework. A prototype framework was created.

Participants supported the concept of a structured approach to communication in these scenarios, and delineated 9 key elements of a framework: (1) formulating prognosis, (2) creating a personal connection, (3) disclosing information regarding the acute problem in the context of the underlying illness, (4) establishing a shared understanding of the patient’s condition, (5) allowing silence and dealing with emotion, (6) describing surgical and palliative treatment options, (7) eliciting patient’s goals and priorities, (8) making a treatment recommendation, and (9) affirming ongoing support for the patient and family.

Communication with seriously ill patients in the acute setting is difficult. The proposed communication framework may assist surgeons in delivering goal-concordant care for high-risk patients.