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PubMed1990

Modified processing of prescriptions for discharged patients.

A process for designing and implementing a new procedure for handling discharge prescriptions is described. Hospital administration requested that the pharmacy department develop a new procedure to handle discharge medications. The old procedure, in which discharge prescriptions were filled by decentralized pharmacy personnel and delivered to patients' rooms, resulted in lost revenues from third-party payers and in delays for patients leaving the hospital. Under the new procedure, prescriptions are given to patients at the time of discharge; these prescriptions then may be filled either at the central ambulatory-care pharmacy or at a community pharmacy. This new procedure was designed and implemented according to a planned approach: (1) reviewing the problem, (2) evaluating the arguments for and against change, (3) using strategies to minimize resistance, and (4) evaluating the results. Resistance of pharmacy personnel, physicians, nurses and patients to the new procedure was managed by allowing pharmacy personnel to participate in the design of the new procedure; educating all affected hospital staff members about the procedure; structuring the procedure to address the problems of delayed discharge and patient ability to pay for medications; and negotiating with ambulatory-care pharmacists and technicians about the increased workload. The new procedure was implemented on July 1, 1987. The new procedure was evaluated to determine how well it worked and whether continuity of care had been compromised. As a result of this evaluation, the level of staffing and hours of operation of the ambulatory-care pharmacy were increased. A planned approach to implementing a change in the procedure for handling discharge medications was successful in identifying and overcoming resistance to that change.

Aftercare↗
PubMed1999

Dead-on-arrival patients in Panchiao, Taipei.

BACKGROUND: The present emergency medical service (EMS) system in the Panchiao area includes operations in Panchiao, Sulin, Sunshia, Chung Ho and Touchen, which is in the early developmental stage. Educational programs such as emergency medical technician (EMT)-I, and -II have been provided for less than 25% of firefighters in that area. Several mass educational programs in cardiopulmonary resuscitation (CPR) were also provided for the inhabitants of the area. The purpose of this study was to establish a database of dead-on-arrival (DOA) patients during this early stage of the EMS system development so that comparisons of EMS performance could be assessed to identify any future needs of the EMS system in the Panchiao area. METHODS: A patient was verified as DOA if there was no pulse nor a response to stimulation. For every DOA patient, several parameters were recorded in a registration book, which began January 1, 1995, and included the following: name, gender, age, mode of transportation, time to hospitalization, on-scene CPR, prehospital basic life support, possible etiology, response to advanced cardiac life support (ACLS), disposition and outcome. The registration book was reviewed and a follow-up study was designed, which covered the entire year of 1995. RESULTS: There were 292 DOA patients brought to the emergency room of the Far Eastern Memorial Hospital in Panchiao, Taipei, between January 1, 1995, and December 31, 1995. The study population comprised 190 (65.1%) men and 102 (34.9%) women. The mean age of the men was 51.8 +/- 22.3 years (mean +/- standard deviation). The mean age of the women was 59.8 +/- 24.4 years. Emergency service ambulances transported most DOA patients, though a few were transported by private ambulance from nursing homes. There were only two incidents in which prehospital CPR was conducted. The time to hospitalization varied from five to 170 minutes and averaged 38.3 minutes. Following ACLS, 244 (83.6%) patients were pronounced dead in the emergency room. Cardiovascular and respiratory problems were the leading etiologies and trauma was the second. There were 48 patients (16.4%) who responded to ACLS, but only eight (2.7%) survived until hospital discharge. CONCLUSIONS: Delayed initiation of the EMS system resulted in an average time to hospitalization of 38.3 minutes. Cardiovascular collapse was the leading etiology in DOA patients. There were only two patients who received prehospital CPR, suggesting that layperson CPR and EMT education cannot be overemphasized.

Adult↗
PubMedDate not supplied

The PTL, Combitube, laryngeal mask, and oral airway: a randomized prehospital comparative study of ventilatory device effectiveness and cost-effectiveness in 470 cases of cardiorespiratory arrest.

PURPOSE: A prehospital study was conducted to assess and compare three alternative airway devices and the oral airway for use by non-Advanced Life Support emergency medical assistants (EMAs). METHOD: A modified randomized crossover design was used. The Pharyngeal Tracheal Lumen Airway (PTL), the laryngeal mask (LM), and the esophageal tracheal Combitube (Combi) were compared objectively for success of insertion, ventilation, and arterial blood gas and spirometry measurements performed upon hospital arrival. Subjective assessment was carried out by EMAs and receiving physicians at the time of device use, and an eight-question comparative evaluation of all devices was completed by EMAs at study conclusion. A comparative cost analysis was performed. Operating room training was compared with mannequin training for the LM. Autopsy findings and survival to hospital discharge were analyzed. The study took place in four non-ALS communities over four and a half years, and involved 470 patients in cardiac and/or respiratory arrest. EMAs had automatic external defibrillator training but no endotracheal intubation skills. RESULTS: Successful insertion and ventilation: Combi, 86%; PTL, 82%; LM, 73% (p = 0.048). No significant difference was found for objective measurements of ventilatory effectiveness (ABGs and spirometry). Significant comparative differences in subjective evaluation were found. CONCLUSIONS: The PTL, LM, and Combi appear to offer substantial advances over the OA/BVM system. Although the most costly, the Combitube was associated with the least problems with ventilation and was the most preferred by a majority of EMAs.

Aged↗
PubMed1989

The uses of the anesthesia record.

The typical, handwritten anesthesia record of the 1980s does not satisfy its many users. The document is used for clinical care by the anesthetist, nurses, physicians, and technicians in postanesthesia, intensive, and postoperative surgical care units; for historical information by the billing officer, the statistician, and the anesthetist in preparation for a future anesthetic; and for the review of the quality of care by clinical peers and lawyers. For all of these users the typical record contains some to much unnecessary information and lacks some to much needed information. Electronic capture, storage, retrieval, and formatting of data can generate electronic displays or paper records tailored to answer the needs of specific users. The anesthetist in particular will benefit from a well-designed system that takes the place of the traditional handwritten anesthesia record.

Anesthesiology↗
PubMed2005

Biosafety level 3 laboratory for autopsies of patients with severe acute respiratory syndrome: principles, practices, and prospects.

BACKGROUND: During the outbreak of the emergent severe acute respiratory syndrome (SARS) infection, >30% of the approximately 8000 infected persons were health care workers. The highly infectious nature of SARS coronavirus (SARS-CoV) compelled our pathologists to consider biosafety issues in the autopsy room and for tissue processing procedures. METHODS: A specially designed biosafety level 3 (BSL-3) autopsy laboratory was constructed and divided into a clean area, a semicontaminated area, a contaminated area, and 2 buffer zones. High-efficiency particulate air filters were placed in the air supply and exhaust systems. Laminar air flow was from the clean areas to the less clean areas. The negative pressures of the contaminated, semicontaminated, and clean areas were approximately -50 pa, -25 pa, and -5 pa, respectively. Personal protective equipment, including gas mask, impermeable protective clothing, and 3 layers of gloves worn during autopsies; the equipment was decontaminated before it was allowed to exit the facility. Strict BSL-3 practices were followed. RESULTS: When a given concentration of particulate sarin simulant was introduced into the contaminated area, it could not be detected in either the semicontaminated area or clean area, and particles >0.3 microm in size were not detected in the exhaust air. A total of 16 complete postmortem examinations for probable and suspected SARS were performed during a 2-month period. Of these, 7 reported confirmed cases of SARS. None of the 23 pathologists and technicians who participated in these autopsies was infected with SARS-CoV. CONCLUSIONS: Our experience suggests that BSL-3 laboratory operating principles should be among the special requirements for performing autopsies of contaminated bodies and that they can safeguard the clinicians and the environment involved in these procedures.

Autopsy↗
PubMed1986

The pioneer spirit in first assisting.

Unless RNs are willing to accept this responsibility, less trained people will be more than happy to do so. We have given away many of our technical skills in the past, such as allowing technicians to become firmly entrenched in the scrub role. I hope we don't let this opportunity slip through our hands because we have lost the pioneering spirit of our nursing heritage. Thirty years ago, the issue was whether or not nurses could take blood pressures. More recently, it has been whether nurses could use the defibrillator. Now both are accepted without a thought. Those of us who have chosen to expand our practice must be patient with our colleagues who have not had an opportunity to work through both sides of the issue, and encourage them to do so. There will be those who choose not to function in this role, and I believe that first assisting is not for everyone. But in order to have a choice, the option must be there.

Humans↗
PubMed2003

Reducing exposure to laboratory animal allergens.

Laboratory animal allergy is a serious health problem. We examined several possible allergen-reducing strategies that might be effective in the working mouse room. Ambient allergen concentrations were measured when mice were maintained under several conditions: conventional housing versus ventilated cage racks operated under negative or positive pressure. We found that housing mice in ventilated cages operated under negative pressure and using ventilated changing tables reduced ambient mouse allergen (Mus m 1) concentrations tenfold, compared with values when mice were housed in conventional caging and using a conventional (non-ventilated) changing table. Housing mice in positively pressurized cages versus conventional cages did not reduce ambient allergen values. Cleaning mouse rooms at an accelerated frequency also did not reduce ambient Mus m 1 concentration. We also quantified ambient allergen values in several areas of The Jackson Laboratory. A facility-wide survey of Mus m 1 concentrations indicated that allergen concentrations were undetectable in control areas, but ranged from a mean (+/- SEM) 0.11 +/- 0.02 ng/m3 to 5.40 +/- 0.30 ng/m3 in mouse rooms with different cage types. The percentage of animal caretakers reporting allergy symptoms correlated significantly with ambient allergen concentrations: 12.9% reported symptoms in the rooms with the lowest allergen concentration (0.14 +/- 0.02 ng/m3), but 45.9% reported symptoms in rooms with the highest concentration (2.3 +/- 0.4 ng/m3). These data indicate that existing technology can significantly reduce exposure to laboratory animal allergens and improve the health of animal caretakers.

Air Pollution, Indoor↗
PubMed2000

The carotid pulse check revisited: what if there is no pulse?

This study was undertaken to evaluate the diagnostic accuracy and time required by first responders to assess the carotid pulse in potentially pulseless patients. We conducted a prospective, randomized study of first responders (n = 206; four different training levels) and were blinded as to the patients' conditions in the cardiac operating rooms of a university hospital. Sixteen patients underwent coronary artery bypass surgery on nonpulsatile cardiopulmonary bypasses. Carotid pulse check was performed either during pulsatile (spontaneous) or during nonpulsatile (extracorporeal) circulation. Patients' hemodynamic status at the time of assessment, diagnostic accuracy of the first responders, and the time required to diagnose carotid pulsatility or pulselessness were documented. Within 10 secs, only 16.5% of the participants (34 of 206) were able to reach any decision about their patients' pulse status. Assessments that were both rapid and correct (15%, i.e., 31 of 206) occurred almost exclusively in pulsatile patients. Advanced training level shortened the delay to decision and improved its accuracy. However, merely 2% of the participants (1 of 59) correctly recognized a truly pulseless patient within 10 secs. Recognition of pulselessness of the carotid artery by rescuers with basic cardiopulmonary resuscitation training is time-consuming and highly inaccurate. Although the carotid pulse check needs to be taught, its importance in the context of layperson basic life support should be de-emphasized.

Cardiopulmonary Resuscitation↗
PubMedDate not supplied

The effectiveness of a novel, algorithm-based difficult airway curriculum for air medical crews using human patient simulators.

INTRODUCTION: Airway management is one of the most important skills possessed by flight crews. However, few data exist about the efficacy of various educational approaches. Traditional models for airway training, including cadaver labs, operating room exposure, and clinical apprenticeships, are scarce and offer variable educational quality. The objective of this analysis was to evaluate the effectiveness of a simulator-based difficult airway curriculum in a large, aeromedical company. METHODS: Simulation training was integrated into existing airway training for all crew members; an original difficult airway algorithm was used to guide scenarios. To evaluate its effectiveness, rapid sequence intubation (RSI) success before and after curriculum implementation was determined. In addition, crew members rated their confidence with various aspects of airway management before and after exposure to the airway workshops. RESULTS: First attempt and overall ETI success improved from 71.3% and 89.3% before (n=261) to 87.5% and 94.6% after (n=504) implementation of the algorithm and simulation training, whereas the incidence of hypoxic arrests during RSI decreased from 2.7% to 0.2% (p<0.01 for all comparisons). Crew members reported improvements in confidence with regard to all aspects of airway management following participation in the simulation workshops. CONCLUSIONS: A novel, integrated airway management curriculum using treatment algorithms and simulation appeared to be effective for improving RSI success among air medical crews in this program.

Air Ambulances↗
PubMed2005

Operating theatre nurses: emotional labour and the hostess role.

Emotional labour has been established as a significant factor in nursing work, although no studies have been done looking at emotional labour specifically in an operating theatre nursing context. Theatre staff (17 nurses and three Operating Department Practitioners (technicians) were observed in practice over a period of nine months by one of the authors. Each of the staff was subsequently interviewed. The transcriptions of the observation fieldwork notes and the semistructured interviews were analysed for themes and content. The (predominantly female) nurses perceived that one of their responsibilities was 'looking after the surgeons'. We have described this as the 'hostess' role. This role consisted of two major areas of activity: 'keeping the surgeons happy' and 'not upsetting the surgeons'. Examples are given of how this was accomplished through talk and actions. The (predominantly male) operating department practitioners did not see this as part of their work. This 'hostess' role is a kind of emotional labour, but performed with coworkers rather than patients. Like other forms of emotional labour, it is strongly gendered. The emotional labour performed by the theatre nurses was necessary to maintain what has been called elsewhere the 'sentimental order'.

Adult↗