Weekly Review #11

Ian Miller from the Nurse Path had a review on the emotional burden of providing care especially when providing that care presents a moral dilemma. Miller uses the stories of the staff who cared for both the victims and, more to the point of the discussion, the perpetrator of the 1996 Port Arthur massacre. Miller discusses some of the cardinal signs and symptoms of the stress response, and the role of Critical Incident Stress Management (CISM) in helping providers to cope with moral trauma. I think there's more for nurses here than simply how to look after people who have done bad things; it serves as a talking point on PTSD and role of CISM services. Occupational stress doens't come only from conflict, from massacres, or from trauma; it can come from the consistent emotional burden of providing care. There has been increased attention paid to the fact that stress is claiming the lives of many care providers through either suicide or substance abuse. Looking for help is good, it's normal, I think we all need to discuss and normalize the burden of care, I'm glad to see Ian Miller is doing just that.

http://thenursepath.com/2015/07/24/when-good-people-must-care-for-bad-people/

Great posts by Christina Shenvi and Jacob Avila from the ALiEM team this week. Jacob Avila had a novel approach to confirming IO placement. This post reviews an animal study that found the "squeeze test" to be an effective method for confirming IO placement in porcine extremities. The basic idea is that you compress the area around the IO cannula and observe for changes in the flow rate. If the IO is placed correctly in the bone compressing the soft tissue should have no effect on the flow rate. This seems like a quick way to trouble shoot a questionable IO placement. I don't think it could be considered a true "confirmation" of placement, but if you're using IO access the odds are good that whatever you're doing will need to suffice for a presumptive positive placement.
http://www.aliem.com/trick-of-the-trade-squeeze-test-for-confirmation-of-io-placement/


Christina Shenvi posted a review of delirium in older adults. She discusses diagnostic criteria, the concepts of "homeostenosis"- the narrowing of physiological reserve and ability to compensate for insult, predisposing factors, and management. She uses the DELIRIUM mnemonic to look for precipitating factors:
Drugs- Medication side effects, sedatives, as well as drug interactions can lead to acute delirium
Electrolyte Abnormalities
Lack of Drugs- Withdrawal from opioids, benzos and alcohol.
Infection- not just CNS infection buut also UTI and pneumonia
Reduced sensory input- Not having access to vision/hearing aides can worsen delirium
Intracranial pathology- CVA, tumors, or intracranial bleeds,
Urinary/fecal retention
Mocardial/Pulmonary- Infarct or diseases reducing gas exchange can lead to hypoxia and confusion

http://www.aliem.com/delirium-in-older-adults/




Simon Laing from HEFTEMCAST had a truly fantastic post on EMS handovers. He reviewed the amount of critical information that is typically missed in handovers (72.9%). He provided advice on taking handovers: shut up, maintain eye contact, and don't interrupt (handover time reduced by 15%, interruptions by 93-41%, and EMS needing to repeat information reduced by half!). He gives some general recommendations about the usefulness of structured handovers- a MIST handover, to the designated team lead. This is one of the best post or podcasts I've seen in the last while, it's a free evidence based human factor intervention. Definitely worth a listen for all providers.

http://www.heftemcast.co.uk/ems-handover-make-a-difference-to-all-alerted-patients/




Neuraz et al., published a study in Critical Care Medicine examining the relationship between staffing levels and workload and patient mortality. This study was a longitudinal review of 8 French teaching ICU's. It examined all (5718) patients cared for during 2013 (11,666 shifts). staffing level information was determined by examining billing/staffing databases and merged with patient information that was retrieved from medical records. The primary outcome measure was patient mortality per shift (patients with DNR's were excluded).

Mortality rates (adjusted to age, SAPS score, diagnosis, sex, and comorbidity) were compared to nurse and physician staffing levels, as well as to workload. Nurse patient ratios were split into quintiles ([N:Pt] 1:≤1, 1: 1.1-1.5,  1: 1.6-2.0,  1: 2.1-2.5,  1: >2.5). Physician to patient ratios to quartiles ([P:Pt] 1:≤8,  1: 8.1-10,  1: 10.1-14,  1: >14). Turnover rate (admission+discharges) and the number of life sustaining procedures (LSP) performed in a shift were used as corollaries for workload.

The average(SD) shift had a patient load of 1.8(0.4) patients per nurse, which tended to be fairly constant across shift times (AM vs PM), though higher on weekends. There were on average 5.6(3.2) patients per physician, with a fairly significant difference between day and night periods (~4 vs. 8). Turnover averaged 6.9(9.0) patients per shift, the majority occurring during the day (0700-1900hrs), unit census averaged 13.3(5.1) patients, with 1.3(0.3) LSP performed per shift. The typical patient was a 60.6(4.9) year old male (0.7[0.1]) surgical patient (0.6[0.1]) with a SAPS score of 50.5(6.4).

Neuraz et al., recommend a threshold of 14 patient per physician and 5 patients per 2 nurses. Patient mortality increased when patient to nurse ratios exceeded 2.5 (RR 3.5[1.3-9.1]), when patient physician ratios exceeded 14 (RR 2.0[1.3-3.2]), and as workload and patient acuity increased (turnover adjusted risk RR 5.6 [2.0-15.0], LSP RR 5.9 [4.3-7.9], SAPS 1.5 [1.3-1.7]).

This study is not the first to examine the relationship between staff ratios and mortality, but it is one of the few to examine daily staff compliment as a continuous value (rather than the traditional method of discrete fixed staff ratios). It also acknowledges that it's workload, the timing of the work and not just the staffing ratios that have the largest effect on patient outcomes. From a nursing perspective I don't think that there's any particularly surprising news here; we call all appreciate that as patient staff ratio and clinical acuity increase so too do adverse outcomes. But I think that this research is important, it moves away from examining fixed patient nurse ratios to examining continueous data. It provides a framework that future studies could use in environments where patient to staff ratios are higher and workload more variable.

http://www.ncbi.nlm.nih.gov/pubmed/?term=25867907