Emergency Department Care Reconsidered

 

By Jeffrey E. Phillips BS, RN

What is patient care in the emergency department (ED) supposed to be about? Patients arrive either presenting with an already concluded diagnosis (e.g., “I cut my finger”, “I fell”) and require treatment, or a patient arrives with a set of symptoms that must have a diagnosis assigned to them (e.g., headache, chest pain, abdominal pain). In either possibility, the staff must determine the severity of the complaint, decide on a mode a treatment, and then transition the patient to treatment outside of the ED. That transition may be in the form of admission to the hospital, transfer to another facility, or discharge with or without primary care follow-up. Or in the words of emergency medicine physician, Dr. Ken Milne, “meet ‘em, greet ‘em, treat ‘em, and street ‘em” (Milne, 2014).

Our responsibility to our patients in the ED is about early intervention, stabilization, treatment, and transition, although according to Dr. Scott Weingart of Stony Brook University Hospital, it is much more than that. “Bring upstairs care, downstairs,” is the mantra Weingart tries to impart on those who will listen (Weingart, 2009). In a more verbose translation, he is advocating that the depth of care provided in the Intensive Care Unit (ICU) be provided in the ED as well. Of course Weingart is referring to the sickest of patients, those requiring the most intensive resuscitation efforts. But what about those patients outside of the resuscitation rooms; the rule out septicemia, the decompensated nursing home transfer, the undifferentiated abdominal pain? The concept of providing ICU or “floor” level care can be expanded to any patient in the ED. In the same way, the concept of providing excellent care goes beyond medicine and into nursing as well, or at least in theory it should.

As a gross generalization, emergency care boils down to treating emergent complaints and supporting airway, breathing and circulation (ABC) until the patient can be transferred to a facility or unit that is capable of more appropriately handling the patient’s condition. But in the modern, urban emergency department, overcrowding, long admission wait lists, and unsanitary conditions dampen what should be a seamless extension of excellent hospital care. The increase in patient visits coupled with the extended stays in the ED, both demand improved nursing care and also reduce the ability to provide it. As the patient census rises, and nurse-to-patient ratios creep into the teens, the ability to provide comprehensive care steadily diminishes. A patient load of twelve or fifteen patients devolves nursing care to the bare necessities of ensuring safety, monitoring ABCs, and providing “essential” treatment at the expense of quality patient-centered care.

emergency room     The implications of Dr. Weingart’s philosophy on medical practice is a conversation for another day. Discussions about whether to perform needle or knife cricothyrotomy, or when to implement extracorporeal membrane oxygenation on post-cardiac arrests patients is best left for medical experts to debate. The question posed here is whether Dr. Weingart’s philosophy of bringing floor level medical care in the ED can be extended to nursing care. Can nursing care bo optimize so that nurses go beyond efficiently keeping patient’s vitals stable and inserting IVs and Foley’s in the ED.

Something must change in this era when it is not unusual for 40% of patients in ED to be admitted, when the average wait time for an in-patient bed might take over 24 hours. It is interesting to consider how ED nurses perceive the level of care provided to “admitted” patients in the ED, those who are in transition limbo, praying for a bed (note to nursing students: this is an excellent researchable PICO project!). It is ironic that patients could be horizontal in the ED, but waiting for a bed. They are “resting” but yet there is something restless about and around them. How is the care different to the same type of patient, but one is “waiting” in the ED and the other is “waited on” in the medical-surgical unit? How do nurses make the distinction?

To illustrate this, let’s consider a scenario. Say an ED nurse is walking along a crowded corridor and saw an adult patient, tucked away in a corner stretcher, crying. The nurse recognized the patient as “not one of my patients”. Will the nurse go in and find out what’s happening with this patient. Or will the nurse simply walk on by and brush off the scene as “not an emergency” and move on perform another task? The incomplete explanation on what influences a nurse’s response to potential nursing moment in any setting is personal values. Every nurse agrees that nursing is the skilled (crafty in the positive sense) application of healing sciences, but ultimately it is also an attitude and a reflection of what the nurse holds true in his or her heart.

To fully integrate the ongoing ED initiatives to improve patient experience such as hourly rounding, reducing falls, decreasing incidence of left-without-being-seen, and providing timely antibiotic or discharge instructions requires a reflective recalibration of the collective and individual attitude of ED nurses or all nurses for that matter. It is troubling to note that medical records contain a disclaimer when a nursing procedure was performed in the ED (e.g., Foley insertion) as if it is probable that sterility may have been compromised. Floor level or ICU level nursing in the ED cannot be achieved by drive-by in-service but through careful consideration of personal values, mentorship and coaching, the use of checklists, and purposeful huddle to truly put patients first.

Increasing number of sicker patients will continue to descend upon the doors of EDs. In 2010, the number of visits to the ED increased by 32% nationwide, from 102.8 in 1999 to 129.8 million (Centers for Disease Control and Prevention, 2010). ED nurses, being the first nursing care contact of patients, will continue to rise to the challenge of implementing the same nursing care benchmarks for inpatients and leave a lasting positive impression in the patient beyond triage. Nurses save lives not just by cardiac compressions, but also holding our patients’ hands. In this regard, we are all floor nurses, no matter where we work.

 

References

Centers for Disease Prevention and Control. (2010). National Hospital Ambulatory Medical Care Survey: 2010 Emergency Department Summary Tables. Retrieved from http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf

Milne, Ken MD (2014, Nov 16). The Skeptics Guide to Emergency Medicine (Audio Podcast). Retrieved from http://thesgem.com

Weingart, Scott MD. (2009, Mar 1). Emcrit Podcast (Audio Podcast). Retrieved from http://emcrit.org

 

Jeffrey PhillipsJeffrey E. Phillips BS, RN works in the Emergency Department at New York-Presbyterian Weil-Cornell Medical Center. Disclaimer: The views expressed in this essay are my own opinion and personal observations of patient care.

Propofol infusion syndrome: A rare but lethal complication

BY: Chen, Leon MS, RN, AGACNP-BC, CCRN, CPEN; Lim, Fidelindo A. DNP, RN, CCRN

MR. A, 48, WAS DIAGNOSED with diffuse large B-cell lymphoma and central nervous system involvement. Despite several rounds of chemotherapy and stem cell transplantation, his clinical status deteriorated. When video electroencephalography monitoring demonstrated refractory status epilepticus (RSE), he was transferred to the neurology observation unit of an urban cancer facility. RSE is defined as ongoing seizures following first- and second-line antiepileptic drug (AED) therapy.1

Mr. A required endotracheal intubation and mechanical ventilation. Despite multiple AEDs, including benzodiazepines, fosphenytoin, phenobarbital, valproic acid, and levetiracetam, he required a propofol infusion for subclinical seizure activity (no clinical or outward manifestation of the electrical seizure activity).2Burst suppression is a state of depressed brain activity achieved with anesthetics that’s used to combat status epilepticus.3 It wasn’t achieved despite a propofol infusion at 6 mg/kg/hr for more than 96 hours. Mr. A then developed a sudden onset of severe metabolic acidosis (serum lactic acid, 7 mmol/L [normal, less than 2 mmol/L]), profound refractory bradycardia, and hypotension (systolic BP less than 90 mm Hg) requiring vasopressors. Because he was hemodynamically unstable, he was transferred to the ICU.

In the ICU, Mr. A was found to have severe metabolic acidosis (pH 7.13) and rhabdomyolysis (creatine kinase 18,453 U/L [normal in males, 38-174 U/L]). His lactic acid level increased to 10.3 mmol/L. Mr. A’s blood specimens were repeatedly corrupted by severe lipemia. For this reason, his potassium level couldn’t be accurately measured. The combination of rhabdomyolysis (muscle tissue breakdown), dysrhythmia, cardiovascular failure, metabolic acidosis, and lab results strongly suggested propofol infusion syndrome (PRIS).

What’s known about PRIS?

An uncommon but potentially deadly complication of prolonged or high-dose propofol infusion, as well as high-dose short-term propofol infusions, PRIS is characterized by metabolic acidosis, hyperlipidemia, and cardiovascular collapse.4,5 Propofol is an ultra-short-acting I.V. sedative-hypnotic agent used primarily for the induction and maintenance of anesthesia or sedation for various indications, including reduction of intracranial pressure and burst suppression for RSE.6 Its rapid onset and elimination allow for quick weaning and neurologic assessments.7

Its anesthetic properties are thought to stem from its inhibition of the gamma-aminobutyric acid receptor, which also makes it effective for seizure suppression.7

In a large prospective study conducted in 2008, 1,017 patients from 11 ICUs who were suspected of having PRIS were observed. The inclusion criteria for PRIS were continuous propofol infusion followed by development of metabolic acidosis and cardiac dysrhythmia with the addition of rhabdomyolysis, hypertriglyceridemia, or renal failure.8 The syndrome was strongly associated with vasopressor use, probably because both propofol and catecholamines can cause muscle necrosis.9 It occurred most frequently after 48 to 72 hours of infusion. In this study, only a small percentage of PRIS cases were associated with a high propofol dose (greater than 4 mg/kg/hr); a dose-dependent relationship has been described in other studies.9

Case reports have described PRIS in patients undergoing burst suppression for RSE who received a high-dose propofol infusion or a large cumulative dose.10 Mr. A was strongly suspected of having developed PRIS while being treated with high-dose propofol for RSE. His rhabdomyolysis, metabolic acidosis, hypoxia, lipemia, and profound bradycardia unattributed to other causes fit the profile for PRIS.

Pathophysiology

Although the exact mechanism of PRIS isn’t well understood, it may be due to propofol’s disruption of the oxidative pathway in the mitochondria, leading to inhibition of adenosine triphosphate production in muscle tissues.11 This in turn causes diffuse cellular hypoxia and muscle necrosis.12 The muscle necrosis is further exacerbated by the catecholamine surge or increased vasopressor requirement secondary to cardiac depression resulting from propofol infusion.11

PRIS is considered a pharmacogenetic phenomenon, suggesting that some patients may have a specific susceptibility to the disease.13 A mitochondrial defect may predispose some patients to PRIS.14

Diagnostic criteria

Current diagnostic criteria include rhabdomyolysis, hyperkalemia, hyperlipidemia, renal failure, and Brugada-like electrocardiographic abnormalities, which includes ST-segment elevation (2 mm or greater) in leads V1 to V3 with the elevated ST segment descending with an upward convexity to an inverted T wave. This is referred to as the “coved type” Brugada pattern.12,15 Lipemia and elevated triglyceride levels have been documented in PRIS and may be the result of enhanced sympathetic nervous system stimulation and increased lipolysis.11 Additionally, propofol’s lipid emulsion is thought to cause accumulation of free fatty acids, leading to dysrhythmia.12 The patient shouldn’t have any known cause of heart failure or evidence of sepsis or multiorgan failure.

Currently, no standardized PRIS screening tool has been developed. A screening protocol based on creatine kinase and lactic acid levels has been studied in a single-center trial, but external validity hasn’t been established.11 The lack of a standardized screening tool for PRIS presents a challenge because many of the presenting signs (such as metabolic acidosis) are common in critically ill patients or are adverse reactions to propofol, such as bradycardia.9 Mr. A’s risk factors for PRIS are young age, RSE, I.V. vasopressor administration, high-dose propofol, and 96 hours of therapy.11

Nursing implications

In patients receiving I.V. propofol who have risk factors, including high doses (more than 4 mg/kg/hr), prolonged use (longer than 48 hr), critical illness, concomitant use of vasopressors or steroids, low carbohydrate intake, and relatively young age (less than age 55), hold a high index of suspicion of PRIS.11

Interdisciplinary collaboration among nurses, healthcare providers, and pharmacists is essential for the prompt recognition and treatment of PRIS. As part of surveillance for PRIS, critical care nurses should closely monitor arterial blood gas analysis results and serum metabolic profile, lactic acid, triglyceride, and creatine kinase levels, as well as liver profile and renal function study results. Nurses should also monitor results of ECGs and promptly report any episodes of hemodynamic instability.

Once signs and symptoms are recognized, immediately discontinue the propofol infusion and notify the healthcare provider. Though successful resuscitation with extracorporeal membrane oxygenation has been described in a case report,7 currently there are no definitive treatment guidelines apart from prompt discontinuation of propofol and supportive care.

In the ICU, Mr. A received supportive management that included fluid resuscitation, bicarbonate infusion, vasopressors, and serial monitoring of lab work. He was maintained on mechanical ventilation, his vital signs and urine output were closely monitored, and hourly neurologic assessments were performed.

Fatal outcome

Due to the heterogeneity of study criteria, illness presentation, and patient population studied, actual incidence and mortality of PRIS aren’t known. However, in spite of low estimated incidence rate (1%), the reported mortality ranges from 18% to over 50%.11

In this case, the propofol infusion was discontinued immediately once PRIS was suspected. Mr. A continued to receive benzodiazepines with close monitoring of hemodynamics. Unfortunately, despite optimal supportive care in the ICU, Mr. A experienced cardiac arrest and was unable to be successfully resuscitated.

Prevention

Because no antidote for propofol exists, prevention is particularly crucial. An algorithm for preventing PRIS has been proposed but hasn’t been studied in clinical trials.16 Besides using alternative methods of sedation,9 preventive measures include infusing the lowest dose of propofol for the shortest duration, minimizing lipid load (concentrating propofol drip and adjusting parenteral nutrition), providing adequate carbohydrate intake, and stopping the propofol infusion at the earliest signs of abnormal lab results and/or ECG changes.10,11

Critical care nurses play a major role in early detection and prevention of PRIS by actively collaborating with healthcare providers during bedside rounds and periodic safety huddles during the course of treatment. Nurses can take leadership roles in designing quality improvement projects to prevent PRIS through shared governance committees. Evidence-based screening tools and definitive diagnostic guidelines need to be developed and implemented to improve patient outcomes.

 

REFERENCES

1. Stecker MM. Status epilepticus. UpToDate. 2014. http://www.uptodate.com.
2. Wilfong A. Overview of the classification, etiology, and clinical features of pediatric seizures and epilepsy. UpToDate. 2014. http://www.uptodate.com.
3. Amzica F. Basic physiology of burst-suppression. Epilepsia. 2009; 50:(suppl 12):38–39.
4. Hwang WS, Gwak HM, Seo DW. Propofol infusion syndrome in refractory status epilepticus. J Epilepsy Res. 2013; 3:(1):21–27.
5. Tietze KJ, Fuchs B. Sedative-analgesic medications in critically ill adults: properties, dosage regimens, and adverse effects. UpToDate. 2014. http://www.uptodate.com.
6. Propofol Injectable Emulsion [package insert]. Hospira, Inc., Lake Forest, IL; 2009.http://www.hospira.com/Images/EN-2029_81-5641_1.pdf.
7. Mayette M, Gonda J, Hsu JL, Mihm FG. Propofol infusion syndrome resuscitation with extracorporeal life support: a case report and review of the literature. Ann Intensive Care. 2013; 3:(1):32.
8. Roberts RJ, Barletta JF, Fong JJ, et al. Incidence of propofol-related infusion syndrome in critically ill adults: a prospective, multicenter study. Crit Care. 2009; 13:(5):R169
9. Imam TH. Propofol-related infusion syndrome: role of propofol in medical complications of sedated critical care patients. Perm J. 2013; 17:(2):85–87.
10. Iyer VN, Hoel R, Rabinstein AA. Propofol infusion syndrome in patients with refractory status epilepticus: an 11-year clinical experience. Crit Care Med. 2009; 37:(12):3024–3030.
11. Schroeppel TJ, Fabian TC, Clement LP, et al. Propofol infusion syndrome: a lethal condition in critically injured patients eliminated by a simple screening protocol. Injury. 2014; 45:(1):245–249.
12. Cremer OL. The propofol infusion syndrome: more puzzling evidence on a complex and poorly characterized disorder. Crit Care. 2009; 13:(6):1012
13. Annen E, Girard T, Urwyler A. Rare, potentially fatal, poorly understood propofol infusion syndrome. Clin Pract. 2012; 2:(3):e79
14. Savard M, Dupré N, Turgeon AF, Desbiens R, Langevin S, Brunet D. Propofol-related infusion syndrome heralding a mitochondrial disease: case report. Neurology. 2013; 81:(8):770–771.
15. Wylie JV, Garlitski AC. Brugada syndrome. UpToDate. 2014. http://www.uptodate.com.
16. Testerman GM, Chow TT, Easparam S 4th.. Propofol infusion syndrome: an algorithm for prevention. Am Surg. 2011; 77:(12):1714–1715.

A full text version of this article can be found on the Nursing 2014 website at: http://journals.lww.com/nursing/Fulltext/2014/12000/Propofol_infusion_syndrome__A_rare_but_lethal.4.aspx
 

Leon ChenLeon Chen, MSc, AGACNP-BC, CCRN, CPEN
Leon Chen is Critical Care Medicine Nurse Practitioner of the Department of Anesthesiology and Critical Care Medicine at Memorial Sloan Kettering Cancer Center. He also serves as Adjunct Clinical Faculty for NYU College of Nursing and is a graduate of NYUCN’s bachelors and masters programs.

 

 

Fidel Lim Photo (2)

Fidelindo Lim, DNP, CCRN

Fidelindo Lim is a clinical faculty at NYU College of Nursing and a per diem nurse educator for NYP Weill Cornell and Hospital for Special Surgery.

Your Patient Wants to Thank You For…

BY: Fidelindo Lim, DNP, CCRN

In December 2001, the graduating class of New York University’s College of Nursing asked me to give a speech during their pinning ceremony. As part of nursing education, the pinning ceremony goes back to the time Queen Victoria presented a pin to Florence Nightin­gale for her pioneering work during the Crimean war.

Today, a pin may be presented to a graduating nursing student by a faculty member, a mentor, or a loved one as a symbolic welcome to the profession. My own pinning happened in 1987, and I still recall the overwhelming emotion I experienced as I inched ever closer to becoming a nurse.

It’s not easy to think of something original to say to a group of enthusiastic future nurses. The NYU program coordinator suggested I speak from the heart. After digging deep into my heart—hoping to channel Florence Nightingale—I decided to share my impressions of what patients thank us for when they say “Thank you, nurse.” Over the years, I’ve noticed that the predominant theme of those thank-you cards we get from patients is gratitude for the little things we do for them—answering the call light promptly, speaking compassionately, giving them something to drink, placing the phone by their ear when they’re unable to, holding their hand, bringing them a newspaper, and (my personal favorite) trimming their nails and washing their hands. (I did so much of that I could have been accused of illegally practicing podiatry or cosmetology!) I never heard a patient say, “Thanks, nurse. That catheter was really fabulous!” But many patients recall, even years later, the time you washed their hair because they couldn’t walk to the shower.

Recently, when I reread Florence Nightingale’s Notes on Nursing: What It Is, and What It Is Not, I realized she was writing about similar little things. Referring to keeping the bedside spotless and other housekeeping issues, she admonished, “If a nurse declines to do these kinds of things ‘because it is not her business,’ I should say that nursing was not her calling.” These little, seemingly menial gestures may not get us nominated for the Nobel Peace Prize. But as with peacemakers, what nurses do moves and soothes the human heart and spirit. The enchanting (though not entirely mysterious) thing is that as we strive to bring about positive changes in our patients, we’re transformed ourselves. I’m certainly not the same “nurse-person” I was at my pinning ceremony 28 years ago.

In one of the final post-conferences of my undergraduate training, we were asked what field of nursing we were interested in practicing. I enthusiastically replied that I’d like to be a nurse-teacher so I could touch more lives in a shorter time through health education (I imagined a classroom of students as opposed to a few patients). I still believe in teaching, but less on merely reaching more nursing students as on touching their lives and influencing them to make patient teaching as routine as taking temperatures. I’m convinced the nurse’s best weapon in the era of incurable diseases is patient education – primary prevention is ever more important.

Today, nurses walk a delicate line between tradition and technology, computer skills and compassionate service. To bring greater awareness to their challenge, I sometimes ask nursing students, “If you were Florence Nightingale, what would you do if your patient’s arterial blood gas results showed a pH of 7.25, carbon dioxide of 58, bicarbonate of 29, and a partial pressure of arterial oxygen of 80?” One time a student replied without missing a beat, “I’d open the windows to provide pure clean air, hold the patient’s hand, and call for immediate intubation.” I grinned with satisfaction that at least for that student, my teaching had been a success.

These days, “pure” perhaps refers to evidence-based knowledge and “clean” to the honest, no-nonsense compassion we give patients. To our new colleagues, I’d like to stress that whatever field of nursing you pursue, don’t forget to do the little things, share your knowledge with all, and invoke Florence Nightingale—the founder of modern nursing for our modern times.

Note: A variation of this article was published in 2009 as The little things we do.  American Nurse Today, 4, 40.

Fidel Lim Photo (2)Fidelindo Lim, DNP, CCRN

Fidelindo Lim is a clinical faculty at NYU College of Nursing and a per diem nurse educator for NYP Weill Cornell and Hospital for Special Surgery.

 

On Becoming a Nurse

BY: Justin O’Leary, MA, BS, BSN (c)

For a long time I believed that my interest in the sciences, which eventually became an interest in medicine and healthcare, meant I wanted to become a physician. Throughout my first undergraduate degree I followed the pre-med track half-heartedly. While my classmates’ primary goals were to become physicians, my goal was to find a career in which I could help people at a level more intimate than a physician. After ruling out medical school, it was hard to determine which career was the proper fit for me. The perfect amount of freedom, responsibility, and variability within a career didn’t exist, or so I thought.

While my classmates’ primary goals were to become physicians, my goal was to find a career in which I could help people at a level more intimate than a physician.

After graduating from Binghamton University, I began to volunteer full time at the Nassau County Department of Health in the Bureau of Communicable Disease Control. Working side by side with public health nurses, I was immersed in new experiences and found myself becoming more familiar with the role of nurses in public health. Fortunately, these individuals I worked with held a plethora of knowledge, coming from various nursing backgrounds. Hearing experiences from working on the hospital floor to long-term home care I realized nursing offered me the various options I looked for within a career. As a nurse, I would have the flexibility to continually build upon my base knowledge to further enhance my abilities to provide exceptional care. Working at the Nassau County Health Department was the catalyst for my nursing epiphany. I had found a profession that would allow me to combine all of my strengths and interests to help others.

Working at the Nassau County Health Department was the catalyst for my nursing epiphany. I had found a profession that would allow me to combine all of my strengths and interests to help others.

One of my work colleagues, a man who had worked in many professions, truly motivated me to consider nursing as a career choice. As someone who had entered the field later in life after numerous other professions, this individual became of the most knowledgeable and hard working public health nurses I have met. As an immigrant, he informed me that nursing was not held in a high regard as it is here and is not considered a career for men. During his time as a medical technologist, the perceived barrier to nursing became less obvious as he was drawn to the profession and encouraged by those around him. Hearing his experiences helped shatter my own perceived barrier to entering the field. I was fortunate enough to learn from his experiences and have a role model I could relate to as I entered into the field of nursing myself.

How can nursing attract more men to the field? I’m not sure of the answer at the moment, but hopefully one day as a nurse I will have that answer.

Returning to school to earn a second bachelors degree in a predominately female-dominated profession raised mild concerns over my acceptance by my classmates and the effect on my learning and success within the program. Surprisingly, I found a larger male population within my cohort than anticipated and am also happy to report acceptance by my female colleagues. As I progressed in my nursing program I noticed that specific populations were covered and student interest groups revolved around women’s health but not specifically men’s health. This sparked a thought: if men’s health was covered more specifically in nursing curriculum, would that attract more men into the profession? Some women flock to the profession to be midwives or care for women with breast cancer but how many men flock to the profession to help others with prostate problems or testicular cancer? How can nursing attract more men to the field? I’m not sure of the answer at the moment, but hopefully one day as a nurse I will have that answer. 

As a nursing student, my primary goal is to obtain as much experience as possible in a hospital setting following graduation and licensing. I have realized while both volunteering inthe hospital and at the health department that high-quality entry level education is of the utmost importance, but nothing beats firsthand bedside experience. Hands-on-learning stays with a person and is a necessity for further developing a person’s skills and advancing within the field. It is my goal after working for a couple of years to eventually enter an advanced degree program, although at this point in my career I am unsure as to which. Having interests in various nursing specialties, my clinical experiences during nursing school will provide me with a more in depth understanding of each field.

In the advent of Ebola and other emerging infections, I am more convinced that nurses will play a vital role, as they have proven during the AIDS crises and other singular epidemics in history such as the flu pandemic of 1918.

My experience at the health department has interested me in possibly becoming an infection control practitioner in a hospital after gaining experience at the bedside. In the advent of Ebola and other emerging infections, I am more convinced that nurses will play a vital role, as they have proven during the AIDS crises and other singular epidemics in history such as the flu pandemic of 1918. I may eventually re-enter public health later in my career. A transition from helping an individual to helping a community would provide a fresh change and keep the dynamic field of nursing novel. I may be a novice nurse at the moment, but I look forward to a lifetime of learning and developing myself to be an expert in the field.

 

justinoleary

Justin O’Leary, MA, BS, BSN (c)

Justin O’Leary is in his final semester in NYU’s Accelerated Bachelor of Science in Nursing program (December 2014 Graduate).  After earning a Bachelor of Science in Integrative Neuroscience and a Master of Arts in Biological Sciences from Binghamton University, State University of New York, Justin spent a year at the Nassau County Department of Health in communicable disease control before entering into nursing. O’Leary is a Robert Wood Johnson Foundation New Careers in Nursing Scholar and currently volunteers at Bellevue Hospital in the Emergency Department. Justin is a recipient of the AAMN Foundation Scholarship.  

Sepsis Management: I Still Haven’t Found What I’m Looking For

BY: Leon Chen, MSc, AGACNP-BC, CCRN, CPEN

sepsis1The word “sepsis” comes from ancient Greek and means decay, no doubt describing the rotting flesh of those afflicted with this condition. Descriptions of septic manifestations have been described as early as Hippocratic times. In our time it remains an epidemiologically important condition, affecting approximately 300,000 people annually in the U.S. In spite of advances in diagnosis and management in the last decade, its mortality rate is still as high as 30%.

Anecdotally, sepsis management used to involve putting a patient in septic shock on dopamine drip, leave him in a corner of a busy emergency room and essentially forget about him and leave him to his own devices. Recognition of a septic patient was not prompt and even when diagnosis was made; treatment plans were inadequate at best. Then in 2001, a game-changer came in the form of the Manny Rivers’ Early Goal Directed Therapy (EGDT) in Severe Sepsis and Septic Shock Trial, commonly known as the Rivers’ trial.

In the EGDT trial, Dr. Rivers protocolized an aggressive recognition and treatment algorithm to resuscitate those found to be in severe sepsis or septic shock. In the randomized control trial, the treatment arm (those who were treated following the EGDT protocol) achieved an astounding level of mortality benefit that to this day has not been reproduced. Despite the lack of reproducibility, the EGDT protocol became the cornerstone of sepsis resuscitation and is the backbone of the Surviving Sepsis Campaign 6-hour bundle. Early screening for sepsis, source control, early antibiotic usage and aggressive fluid infusion became widely implemented.

sepsis3

Dr. Emanuel Rivers who proposed Early Goal Directed Therapy (EGDT) in Severe Sepsis and Septic Shock Trial.

In spite of the popularity of the EGDT protocol, EGDT is not without its critics. One prominent voice of dissent comes from Dr. Paul Marik, who published paper after paper criticizing EGDT’s various components, most notably, the external validity of this single center study with a unique population, the use of invasive monitoring to guide resuscitation and aggressive fluid resuscitation. As Manny Rivers’ EGDT protocol became widely standardized in institutions worldwide, it became apparent that compliance to place invasive monitoring for every septic patient in the EDis difficult due to the high patient volume and lack of providers. Likewise, evidence against various components of EGDT such as usage of central venous oxygen saturation, central venous pressure to gauge fluid status started to become overwhelming.

Though the core of EGDT, which are early recognition and aggressive treatment, stands the test of time, other components are starting to erode in the face of mounting newer evidence. The Emergency Medicine Shock Research Network (EMShockNet) Investigators trial on lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy demonstrated that lactate clearance as a resuscitation goal is non-inferior to that of central venous oxygen saturation.At the same time, Marik and Cavallazzi’s2011 meta-analysis debunked the myth of central venous pressure measuring fluid responsiveness.Both studies brought doubt in the necessity of invasive monitoring. What once seemed like the gold standard for sepsis management is no longer the unquestionable truth.

Three large multi-centers randomized controlled trials, ProCESS, ARISE and PROMISE set out to answer the question whether EGDT really is better than traditional care, where resuscitation is guided by provider’s judgment. When ProCESS trial findings was published earlier this year, the naysayers of EGDT rejoiced in unison since the EGDT group did no better than the standard care group who didn’t receive any fancy monitoring or get a ton of fluids. Surviving Sepsis Campaign stood firm against calls for change to current recommendations, citing the need for more evidence.

Less than a year after the publishing of ProCESS trial, ARISE study findings was published, further supporting that standard care group without invasive monitoring such as central venous catheter or arterial catheter did not have higher mortality than the EGDT group. Both ProCESS and ARISE were methodologically superior to Rivers’ original EGDT trial and this time, Surviving Sepsis Campaign released a statement acknowledging that current best evidence does not support the routine usage of central venous oxygen saturation or central venous pressure, thus negating the necessity of mandatory usage of invasive monitoring.

sepsis2Current recommendation will be reviewed by Surviving Sepsis Campaign and I strongly believe that PROMISE trial will confirm the findings from the ProCESS and ARISE trials and that eventually, Surviving Sepsis Campaign will no longer recommend the routine use of central venous lines for resuscitation endpoint monitoring. Is this the end of EGDT? This is very hard to say since at the core of EGDT lays the need for early recognition of sepsis and I think in the end, this is what saves lives. The STOP sepsis collaborative (http://emcrit.org/podcasts/lessons-sepsis-collaborative/), early results seem to support this concept. It is noteworthy to consider that the ProCESS trial and ARISE trials do not answer to the lingering question regarding the best amount of intravenous fluid or what type of fluid to give. These debates will continue in the future and I look forward to read the results. Ultimately, the Rivers trial’s greatest legacy may be to remove sepsis from our peripheries and place it front and center.

As medical professionals, it’s important to recognize that evidence is fluid and ever changing. One has to be vigilant in obtaining the latest evidence in order to provide optimal care to the patient. It has been estimated that it takes 17 years for research evidence to be translated into practice and this is a disservice to patients. We can shorten the research translation gap through journal clubs and research councils. An innovative approach is to take advantage of social media. Emergency medicine and critical care medicine community are on the forefront of this movement. On the “twitter-verse”, #FOAMed stands for “Free Open Access Medicine education” and it’s a forum for experienced practitioners to share latest evidence and invite instant peer-review. All these innovations in my opinion will likely lead to improved sepsis care.

References

The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-Directed Resuscitation for Patients with Early Septic Shock. N Engl J Med. 2014 Oct 1. [Epub ahead of print]

Balas E, Boren S. Managing clinical knowledge for health care improvement. In: Bemmel J, McCray AT (eds). Section 1: health and clinical management. In Yearbook of Medical Informatics: Patient Centered Systems. Stuttgart, Germany: SchattauerVerlagsgesellschaft; 2000:65-70.

Carlbom DJ, Rubenfeld GD. Barriers to implementing protocol-based sepsis resuscitation in the emergency department–results of a national survey. Crit Care Med. 2007 Nov;35(11):2525-32.

De Backer D, Aldecoa C, Njimi H, Vincent JL. Dopamine versus norepinephrine in the  treatment of septic shock: a meta-analysis*.Crit Care Med. 2012 Mar;40(3):725-30

http://emcrit.org/podcasts/lessons-sepsis-collaborative/

Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA; Emergency Medicine Shock Research Network (EMShockNet) Investigators. Lactate clearance vs central venous oxygen saturation as goals of early sepsis therapy: a randomized clinical trial. JAMA. 2010 Feb 24;303(8):739-46. PubMed PMID: 20179283; PubMed Central PMCID: PMC2918907.

Jones AE, Puskarich MA. The Surviving Sepsis Campaign guidelines 2012: update for emergency physicians. Ann Emerg Med. 2014 Jan;63(1):35-47. doi: 10.1016/j.annemergmed.2013.08.004. Epub 2013 Sep 23.

Kumar A, Roberts D, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006 Jun;34(6):1589-96.

Marik PE1, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med. 2013 Jul;41(7):1774-81. doi: 10.1097/CCM.0b013e31828a25fd.

Marik PE. Early management of severe sepsis: concepts and controversies. Chest. 2014 Jun;145(6):1407-18. doi: 10.1378/chest.13-2104.

MarikPE.Surviving sepsis: going beyond the guidelines. Ann Intensive Care. 2011 Jun 7;1(1):17. doi: 10.1186/2110-5820-1-17.

ProCESS Investigators, A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014 May 1;370(18):1683-93. doi: 10.1056/NEJMoa1401602. Epub 2014 Mar 18.

Rivers, E, Nguyen, B, et al. (for the Early Goal?Directed Therapy Collaborative Group). Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. N Engl J Med. 2001 Nov; 345(19):1368-77

http://www.survivingsepsis.org/SiteCollectionDocuments/ProCESS-ARISE.pdf

 

 Leon Chen, MSc, AGACNP-BC, CCRN, CPENLeon Chen

Leon Chen is Critical Care Medicine Nurse Practitioner of the Department of Anesthesiology and Critical Care Medicine at Memorial Sloan Kettering Cancer Center. He also serves as Adjunct Clinical Faculty for NYU College of Nursing and is a graduate of NYUCN’s bachelors and masters programs.

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Nursing Was Not My Plan B

BY: Luis Sanchez-Vera, BSN, RN, BSPH

At the nurse’s station, the charge nurse switched back and forth between her clipboard and various documents, focused and ready to lead the transition of patient care from the night staff over to the day RN staff. I slowly made my way past the nurse’s station quietly chanting the list of supplies that I needed for the last hour of my shift. Before I could reach the supply room, one of my colleagues sprinted past me yelling, “code blue, code blue, airway!”

I sprinted to the patient’s bedside; a physician was already on scene attempting to suction the blood that was dripping from the patient’s mouth. The patient was familiar; she had been under my care one week prior. Quickly, I raised the head of the bed to stop the patient from aspirating. I opened an additional suction canister and made sure the tubing was connected and ready to go. Before the Yankauer could reach her mouth, copious amount of dark red, projectile vomit forced itself from the patient’s mouth and from both nostrils. The room went silent for one long second. The high-alert alarms abruptly became audible again and our attention centered back to the task at hand. The patient lost consciousness and we instinctively started CPR just as the charge nurse entered the room with the code cart. At this point, I stepped aside and allowed the experienced staff members take over.

My first year as a new graduate at NYU Langone Medical Center has been one of exponential growth, moments of overwhelming challenge but ultimately a fulfilling experience. Being a new nurse, one is plunged into uncharted clinical waters that one never experienced as a student. The nurse residency program at Langone kept me buoyed safely in my transition to becoming an expert. The lectures, skills labs training and shadowing experience all adds up to my on-going professional development.

During orientation, I had to quickly learn about the basic operational duties of the institution. Learning how to page different medical teams, answering phone calls, mastering the electronic medical record and directing family members were just a few of my responsibilities that were essential in order to coordinate the high quality care of my patients. It was extremely important to continually ask contextualized questions with any task or responsibility that seemed unclear in order to promote the safety of my patients. During my first IV insertion attempt, finding the vein for the IV was pretty easy. However, I had to exit and enter the room a few times because I had forgotten supplies and this made my patient increasingly nervous and anxious. I was so embarrassed that I had to keep leaving the room for supplies that it was manifesting in my body language. Ultimately, the patient was uncomfortable with having me insert an IV. I felt slightly crushed but I wanted to respect the patient’s rights and reassure him that he was in safe hands. As I moved forward, I took the time to plan ahead carefully and make sure that I was prepared for every task.

Currently, I am one of four males in my unit. We have always worked as a cohesive team regardless of the male to female nursing staff ratio. One of the challenges I encounter in the field has been defending my decision to become a nurse. Very often, patients would confuse me as a physician. One of the more common questions I am asked is if I would consider pursuing medical school and become a physician. One patient asked, “You’re really smart–why aren’t you a physician?” Nursing is such a dynamic and holistic approach to patient care. I love nursing! The time spent providing direct patient-care at the bedside continues to motivate and validate my decision why I am a nurse.

Nurses are life-long learners, we are continually enhancing our clinical knowledge and life-saving skills in order to provide safe patient-care and most importantly to advocate for our patients. Learning to make plan of care recommendations to the medical team is an invaluable skill that is strengthen with experience. A year ago, my mind seemed to dwell in completing individual tasks and making sure I completed all of my documentation on time. I have so much to learn but I am proud of my growth and increasing confidence at this stage of my career which has been possible largely because of the competent and supportive nursing team on my floor.

As a new nurse, I had to become comfortable with adapting to a continually changing environment. I find myself planning ahead for my shift but often I find patient needs continually changing and having to adjust the plan of care for these patients as well. There have been numerous discouraging moments in my career but I have to learn to reflect on my experiences to allow my confidence to grow and cultivate my professional identity. These reflections are what I have to share to those who are just entering the nursing profession and those who came before me. We are all here for good.

 

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Luis Sanchez-Vera, BSN, RN, BSPH

Luis Sanchez-Vera is a Senior Staff Nurse at NYU Langone Medical Center on a Transplant/Medical-Surgical Floor. The Oregon-native is an NYU College of Nursing alumni and serves as the Mentor Program Coordinator for AAMN’s NYC Men in Nursing Organization. Sanchez-Vera currently works alongside a doctorate level prepared nurse, as part of the Robert Wood Johnson Foundation’s Doctoral Advancement Project, with the intent of pursuing an advanced clinical degree as a Family Nurse Practitioner and eventually a PhD in Nursing. 

 

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Shhh! Too much hospital noise slows recovery

BY: Fidelindo Lim, DNP, CCRN

 “Unnecessary noise, then, is the most cruel absence of care which can be inflicted either on sick or well.” –Florence Nightingale

A recent New York Times article about the negative effects of noise and clatter in hospitals generated a large amount of blog entries. The majority of comments came from patients and nurses who were unanimous in their conclusion that noise in hospitals, particularly in the ICU and other high-acuity units, is a serious threat to the patient’s ultimate recovery.

This reminds me of a time a patient rang her call bell to ask “Is there a cocktail party going on at the nurse’s station?” The din of conversation had kept the patient sleepless and feeling helpless. She was angry and demanded an explanation. Although some hospital noise and sleep interruptions, such as alarms from cardiac monitors, can’t be avoided, much of hospital noise is attributed to preventable sources such as staff conversation.1

shhThe World Health Organization’s (WHO) recommended noise level values for continuous background noise in patient rooms is 35 decibels (dB) during the day and 30 dB at night, with night time peaks not to exceed 40 dB.2 A review of the literature on hospital noise found that compliance to these guidelines isn’t met.1 Recent studies noted high noise levels, at times exceeding WHO’s prescribed noise levels, in various patient-care areas such as the OR,3 burn ICU,4 in medical inpatient units,5 and in chemotherapy clinics.6 The OR is one of the noisiest places, particularly neurosurgery and orthopedic surgery.7 One study reported that the peak noise level during these procedures exceeded 100 dB for almost half the entire procedure.1 There’s no doubt the use of equipment such as drills and saws during orthopedic surgeries contribute to the noise level. Although the effects of prolonged exposure to noise on staff aren’t well understood, the ill effects of noise on patients, most notably significant sleep loss, are well documented.5

Sound check: impact of noise on safety

Noise disrupts sleep. Since adequate sleep is essential to health and well-being, sleep deprivation can lead to a host of ill effects. Sleep disturbance is associated with elevated stress hormone response, hypertension, increased incidence of cardiovascular disease, impaired immune function, attention and memory deficits, and depressed mood.8 These findings are significant considering that cardiovascular diseases are among the leading causes of morbidity and mortality.

In neonatal ICUs (NICUs), stimulation resulting from noise may lead to adverse responses such as increased energy demand and oxygen desaturation.9 Since sound sleep is essential for central nervous system development, sleep disruption may negatively impact the overall health of preterm infants.10 The burden of disease is thereby increased by noise.

Noise not only impacts staff performance, but may also decrease patients’ confidence in their caregivers.

Communication breakdowns and interruptions during patient handoffs happen as a result of noise. The clatter and noise produced during change-of shift report in a crowded nurses station can lead to poor-quality handoffs that result in inefficiency, delayed treatment, mismanagement, and avoidable adverse events.11 High noise levels in the workplace have been implicated in increased staff stress, increased rates of burnout, and reduced occupational health.12 These ill effects of noise will ultimately affect professional behavior, quality of work, workplace civility, and patient safety.

Alarm fatigue and noise desensitization may lead the staff to ignore or disable important alarms.13 The Joint Commission has reported sentinel events related to alarm misuse or inadequate  alarms that resulted in patient deaths.14 Meaningful use of technology to optimize staff response to alarms will promote better sleep for patients and optimal monitoring of critical changes.

Gerontological considerations

Hospitalized older adults are particularly vulnerable to the negative effects of noise and other interruptions due to higher risk for delirium. Although no specific study was found that looked into the role of noise in causing or aggravating delirium in older adults, the interventions used to treat delirium might require noise-generating devices such as infusion pumps and monitors or admitting the patient to the ICU, an inherently loud area where constant monitoring takes precedence over rest and sleep. Delirium is the strongest independent predictor of death, mechanical ventilation time, and ICU stay.15 Sleep deprivation due to noise can potentially exacerbate delirium.

old-man-sleep-heavy-breathingA recent study showed that not all noises are created equal. Electronic sounds (alarms from monitors and infusion devices and the ringing from telephones) caused a greater and more sustained elevation of heart rate.8 This undue cardiac stress (tachycardia) is of particular concern to older adults who might already have underlying cardiac dysrhythmias. An increased heart rate increases myocardial oxygen demand and triggers a cascade of adverse hemodynamic effects in already compromised heart function.

Alarm parameters, for example on heart monitors, should be customized to meet the needs of individual patients. Clinical context and professional judgment play a major part in preventing unnecessary alarms, not only for older adults, but for all patients.24

Noise and patient satisfaction

“I have often been surprised at the thoughtlessness (resulting in cruelty, quite unintentionally) of friends or of doctors who will hold a long conversation just in the room or passage adjoining to the room of the patient, who is either at every moment expecting them to come in, or who has just seen them, and knows they are talking about him.” –Florence Nightingale17

Noise not only impacts staff performance, but may also decrease patients’ confidence in their caregivers.17 This in turn may impact a patient’s hospital experience satisfaction. With the current emphasis on value-based purchasing that’s linked to patient satisfaction scores, hospitals that care for Medicare and Medicaid patients now participate in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) quality survey.18 Patients will be asked to rate how often the area around their room was quiet at night. Based on current data, patients rated the quietness question the lowest of all the quality metrics, responding only 58% of the time that the area around their room was always quiet at night as compared to an average score of 72% for all other metrics.19

Recommendations for best practices

“How well a patient will generally bear, e.g., the putting up of a scaffolding close to the house, when he cannot bear the talking, still less the whispering, especially if it be of a familiar voice, outside his door.” –Florence Nightingale17

The patient-care environment is a powerhouse noise generator. As healthcare becomes more tethered to machines and technology, the pool of noise source increases, in addition to the routine harshness of alarms, paging systems, telephones, computer printers, ice machines, TV, delivery carts, and clipboards.20 Addressing the adverse reactions of noise in healthcare is not new. In 1860, Florence Nightingale’s cutting-edge book Notes on Nursing: What It Is and What It Is Not contained multiple pages devoted to countering the ill effects of noise and how to care for the patient quietly.17 Nightingale emphasized that nurses should speak softly and not rustle around the bedside to keep the noise down.

“A nurse who rustles (I am speaking of nurses professional and unprofessional) is the horror of a patient, though perhaps he does not know why.” –Florence Nightingale.17

Interestingly, a review of research on hospital noise cited nurses’ voices among the most disturbing noise frequently mentioned by patients.20 This is important to note because noise reduction often requires costly architectural solutions. Knowing that talking loudly is the main source of noise, speaking softly would then be the single most cost effective way to reduce noise; an intervention well within the scope of nursing practice.17 Examples of Nightingale’s observations include:
“Never to allow a patient to be waked, intentionally or accidentally, is a sine qua non of all good nursing.”
“…the rattling of keys, the creaking of stays and of shoes will do a patient more harm than all the medicine in the world will do him good.”
“A good nurse will always make sure that no door or window in her patient’s room shall rattle or creak.”
“…unnecessary noise has undoubtedly aggravated delirium in many cases.”
“All hurry and bustle is peculiarly painful to the sick.”

Sleep disturbance is associated with elevated stress hormone response, hypertension, increased incidence of cardiovascular disease, impaired immune function, attention and memory deficits, and depression.

To effectively address noise requires interprofessional collaboration. Reflective discussions among staff, family members, patients, or long-term-care residents on the effect of noise would be a vital first step in designing lasting solutions. Shared governance teams can be powerful change agents. In addressing the noise problem, this multidisciplinary team can assess modifiable sources of noise and create solutions that are achievable. Volume of staff voices can easily be modified by posting signs that promote speaking softly around the nurses’ station. Other modifiable sources of noise are defective equipment such as a broken wheel of a trolley cart and a TV that is left on even when there’s no patient in the room. Controlling noise in the patient-care setting is very much aligned with providing patient-centered care and rests in the domain of nursing. Below are further strategies to curtail noise in hospitals:
• staff-development programs and simulation of “noisy” situations and how to apply best practices
• develop clinical protocols addressing noise and other patient hospital experience satisfaction issues
• designate “quiet time” or “noise time-out” periods, for example, between 2300 and 0600 or between 1400 and 1600
• provide a sleep mask and earplugs as requested by patients
• encourage patients, family, and staff to display a “Do Not Disturb” sign (commonly found in hotel rooms) outside the door during the hours of sleep or during the daytime to allow for naps
• turn off the TV or lower the TV volume whenever possible
• dim the lights at bedtime and close the door as monitoring requirements allow
• keep equipment in good repair
• call environmental services to repair leaky faucets as soon as possible.

Nurse-led initiatives in noise reduction have included installing sound meters in nursing stations to increase awareness of noise levels; installing soft door closers, turning down the volume of phones; setting up conference areas that are not near patient rooms; coordinating care activities to reduce patient disruptions; and conducting random surveys of patients to assess their perceptions of noise levels.21 After a noise reduction initiative, patient satisfaction scores in one facility greatly improved (noise domain) and overall noise level reduction was sustained.22

medical-coverAddressing the noise problem is gaining more attention from practitioners and stakeholders largely due to the Centers for Medicare and Medicaid Service (CMS) ruling on value-based purchasing in which reimbursements will be based on patient experience satisfaction scores. The emphasis on financial incentives might in fact make the hospitals quieter. Interestingly, strategies to curtail noise using sound detection equipment and expensive environmental alterations haven’t proven to be adequate in minimizing hospital noise to levels specified by international agencies.23

The American Association of Critical Care Nurses has published a Practice Alert on alarm management related to monitoring devices such as cardiac monitors.24 This evidence-based clinical practice resource aims to help clinicians apply best practices to avoid alarm fatigue, which will also aid in noise reduction. The full report can be found at http://www.aacn.org/wd/practice/docs/practicealerts/alarm-management-practice-alert.pdf.

An in-depth analysis of noise trends is needed to create policy and practice guidelines that might entail a change in the philosophy of care. All direct patient-care providers in acute care settings need to be aware of the patient’s need for meaningful healing sleep that requires more than just a quiet environment. Care should be coordinated to minimize sleep interruptions during the night or during afternoon naps by avoiding nonurgent interventions such as obtaining vital signs more frequently than needed based on the patient’s clinical status or washing the patient at 0500. A related research question would be to investigate how much sleep loss (hours) is attributable to noise.

Summary

There are approximately 36 million hospital admissions annually in the United States.25 If all healthcare providers took the time to stop and listen to the clatter, we’d be more sensitive to our patient’s comfort needs. In achieving better patient outcomes, we can combine both the wisdom of Nightingale and today’s leading-edge technology in implementing a “quiet approach” conducive to healing and recovery. Care improvements based on HCAHPS survey data has largely focused on communication about medicines, discharge information, and cleanliness. It’s time for all stakeholders to address the hospital noise issue and apply low-cost, evidence-based noise reduction programs. ❖

REFERENCES

1. Bartick MC, Thai X, Schmidt T, Altaye A, Solet JM. Decrease in as-needed sedative use by limiting nighttime sleep disruptions from hospital staff. J Hosp Med. 2010;5(3):E20-E24. doi:10.1002/jhm.549.

2. Berglund B, Lindvall T, Schwela DH. Guidelines for community noise. World Health Organization. 1999. http://www.who.int/docstore/peh/noise/guidelines2.html.

3. Chen L, Brueck SE, Niemeier MT. Evaluation of potential noise exposures in hospital operating rooms. AORN J. 2012;96(4):412-418. doi:10.1016/j.aorn.2012.06.001.

4. Cordova AC, Logishetty K, Fauerbach J, Price LA, Gibson BR, Milner SM. Noise levels in a burn intensive care unit. Burns. 2013;39(1):44-48. doi:10.1016/j.burns.2012.02.033.

5. Yoder JC, Staisiunas PG, Meltzer DO, Knutson KL, Arora VM. Noise and sleep among adult medical inpatients: far from a quiet night. Arch Intern Med. 2012;172(1):68-70. doi:10.1001/archinternmed.2011.603.

6. Gladd DK, Saunders GH. Ambient noise levels in the chemotherapy clinic. Noise Health. 2011;13(55):444-451. doi:10.4103/1463-1741.90322.

7. Ginsberg SH, Pantin E, Kraidin J, Solina A, Panjwani S, Yang G. Noise levels in modern operating rooms during surgery. J Cardiothorac Vasc Anesth. 2013;27(3):528-530. doi:10.1053/j.jvca.2012.09.001.

8. Buxton OM, Ellenbogen JM, Wang W, et al. Sleep disruption due to hospital noises: a prospective evaluation. Ann Intern Med. 2012;157(3):170-179.

9. Wachman EM, Lahav A.The effects of noise on preterm infants in the NICU. Arch Dis Child Fetal Neonatal Ed. 2011;96(4):F305-F309. doi:10.1136/adc.2009.182014.

10. Aita M, Johnston C, Goulet C, Oberlander TF, Snider L. Intervention minimizing preterm infants’ exposure to NICU light and noise. Clin Nurs Res. 2013;22(3):337-358. doi:10.1177/1054773812469223.

11. The Joint Commission. Improving transitions of care: hand-off communications. 2012. http://www.centerfortransforminghealthcare.org/assets/4/6/CTH_Handoff_commun_set_final_2010.pdf.

12. Messingher G, Ryherd E, Ackerman J. Hospital noise and staff performance. The Journal of the Acoustical Society of America. 2012;132:2031.

13. Cvach M. Monitor alarm fatigue: an integrative review. Biomed Instrum Technol. 2012;46(4):268-277.

14. The Joint Commission. Preventing ventilator-related deaths and injuries. Sentinel Event Alert (25). 2002. http://www.jointcommission.org/assets/1/18/SEA_25.pdf.

15. Shehabi Y, Riker RR, Bokesch PM, et al. Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients. Crit Care Med. 2010;38(12):2311-2318.

16. Phillips J. Clinical alarms: complexity and common sense. Crit Care Nurs Clin North Am. 2006;18(2):145-156.

17. Nightingale F. Notes on Nursing: What It Is and What It Is Not. London: Harrison; 1860.

18. Centers for Medicare and Medicaid Services. The HCAHPS Survey—Frequently Asked Questions. n.d. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQuality Inits/Downloads/HospitalHCAHPSFactSheet201007.pdf.

19. Madaras G. A different perspective on the ongoing noise problem in U.S. hospitals: lessons learned from existing acute care facilities and their patients’ quiet-at-night scores. The Journal of the Acoustical Society of America. 2012;132:2032.

20. Pope D. Decibel levels and noise generators on four medical/surgical nursing units. J Clin Nurs. 2010;19(17-18):2463-2470. doi:10.1111/j.1365-2702.2010.03263.x.

21. Eggertson L. Hospital noise. Can Nurse. 2012;108(4):28-31.

22. Connor A, Ortiz E. Staff solutions for noise reduction in the workplace. Perm J. 2009;13(4):23-27.

23. Konkani A, Oakley B. Noise in hospital intensive care units—a critical review of a critical topic. J Crit Care. 2012;27(5):522.e1-522. e9. doi:10.1016/j.jcrc.2011.09.003.

24. American Association of Critical Care Nurses. Alarm management. AACN Practice Alert. 2013. http://www.aacn.org/wd/practice/docs/practicealerts/alarm-management-practice-alert.pdf.

25. American Hospital Association. Fast Facts on US Hospitals. 2013. http://www.aha.org/research/rc/stat-studies/fast-facts.shtml.

The author has disclosed that he has no financial relationships related to this article.

DOI-10.1097/01.CCN.0000443997.85316.c6

Notes: This article was originally published in Nursing 2014 Critical Care: Lim, F. A. (2014). Shhh! Too much hospital noise slows recovery. Nursing 2014 Critical Care, 9, 43-47. A PDF version is available at: Shhh__Too_much_hospital_noise_slows_recovery.10

 

Fidel Lim Photo (2)

Fidelindo Lim, DNP, CCRN

Fidelindo Lim is a clinical faculty at NYU College of Nursing and a per diem nurse educator for NYP Weill Cornell and Hospital for Special Surgery.

 

 

A New Home For The Men In Nursing Of NYC

BY: John Campbell, BSN, BSED, RN
NewYork-Presbyterian/Weill Cornell

Nearly four years into my career, I still occasionally find myself lost in wonder at my good fortune. You see, I am not from around here, both literally and figuratively. I am from suburban Oklahoma by way of the rivers of the Great Northwest, and I could not have predicted a career in nursing. Yet every day at NewYork-Presbyterian/Weill Cornell, I am surrounded by talented, motivated individuals who collectively form the most respected profession in the nation. How did I get here?

When I look back on my long road to a career in nursing, I must admit that being a male plays a large part in finding my eventual destination. Only after studying architecture, working as a wilderness guide, coaching athletics, and riding ambulances as an EMT did I realize nursing was a viable option for a young man. As I first evaluated nursing as a career, I was pleasantly surprised to see nearly all of my interests reflected back at me.

After meeting many other male nurses who share this sense of good fortune despite never considering the career early in life, I came to a two-fold realization. First, these guys are a special group of men. Like our female colleagues, they are personable, intelligent, driven, and compassionate. Yet they set out on a non-traditional path, one that almost no young man hears about as a youth. Second, they are truly rare, generally speaking. Men make up only 9.6% of RN’s nationwide. While many enjoy fulfilling, successful careers as equal participants with female coworkers, I noticed they nevertheless lack a formal organizational structure as a minority group.

During my orientation after joining NewYork-Presbyterian, a conversation on this topic with our Chief Nursing Officer Wilhelmina Manzano, MA, RN, NEA-BC, led to a meeting with Reynaldo Rivera, DNP, RN, NEA-BC, FAAN, Director of Professional Nursing Practice Innovations at NYP. We joined forces with my good friend Fidel Lim, DNP, RN, a professor at NYU and a new member of NYP’s nursing education staff, to embark on a new mission: to start an organization in order to provide a social, professional, and charitable home for the men in nursing of New York City.

Thus, in the fall of last year, we founded the New York City Chapter of the American Assembly for Men in Nursing, a national organization. Now known as NYC Men in Nursing, we offer monthly meetings at prominent local hospitals. Each meeting features a distinguished guest lecturer, followed by a meeting of the board members. We also offer a mentorship program, connecting veteran nurses with students and new graduates.

We gather for events as small as our networking happy hours, and for events as large as our educational conferences. Our spring conference was a landmark success, and we look forward to our Fall Conference on Innovations in Nursing on October 25, 2014, hosted by our very own NewYork-Presbyterian Hospital. Our meetings, events, and membership are open to all interested nurses.

In providing an organizational framework for this group of nurses, we hope to lend one more voice to the national dialogue regarding the nursing profession, while giving something back to the profession which has given so much to us.

For more information, find NYC Men in Nursing online at: https://www.facebook.com/nycchapter

For NYC Chapter AAMN Membership Form: http://tinyurl.com/MembershipNewYorkCityAAMN

Notes: The above article was previously published in NewYork-Presbyterian’s “InReport,” A Newsletter of the Department of Nursing for July 2014 Vol. 10 Issue. 2. Campbell’s original article can be found on page 4 of the newsletter here.

 

john_headshotJohn Campbell, BSN, BSED, RN

John Campbell has been a Registered Nurse for four years since graduating from New York University’s Accelerated Nursing Program in May of 2010.  He currently works in NewYork-Presbyterian/ Weill Cornell’s Cardiothoracic ICU, where he has been for a year.  His other three years as a nurse were spent in NewYork-Presbyterian/ Weill Cornell’s Emergency Department, Bellevue Hospital’s Emergency Department, and Memorial Sloan-Kettering’s Urgent Care Center (emergency oncology).  He is originally from Oklahoma, where he studied architecture at the University of Oklahoma and coached ultimate frisbee.  After leaving Oklahoma, John found his inspiration for becoming a nurse in the Pacific Northwest while working as a whitewater raft guide and EMT, studying wilderness medicine, and teaching CPR/First Aid for the Red Cross.

 

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Shaving As a Metaphor for Nursing

BY: Fidelindo Lim, DNP, CCRN

Over the course of history, people have used metaphors to explain, contrive, reflect, and refute human phenomena. Health care (and all its challenges) has stimulated prolific metaphors to find meaning in its success, but more so in its failures. Military metaphors abound. Health providers are referred to as an “army” who “fight” in the “battleground” against the “enemy,” whether it’s a new strain of resistant organism or a bureaucratic misstep. As health care takes on a business model, metaphors derived from economics become commonplace, turning patients into “consumers” in the competitive “market” of “products and services” with an end-goal of reaching the highest “rating.”
Patients often resort to metaphors to cope with their suffering. Years ago when I was interviewing a patient who came in for rapid atrial fibrillation, he described what he was feeling “as if there was a hummingbird inside my heart; flapping its wings so fast and ready to fly out of there!” The book Illness as Metaphor by Susan Sontag is an example of an eloquent reflection and critique on the use of metaphor in the face of cancer.

Why do we turn to metaphors? The answer is simply because human nature is so vast and mysterious and our language limited. In our search for meaning we draw on symbolic language to derive some sense from our experience. As a nursing faculty, I use metaphors as picturesque clues to illustrate caring that is grounded in an examined experience. One experience I had serves as a metaphor for nursing itself.

A Perfect Picture

One day in August, I assigned a nursing student to care for Mr. C., a homeless 50-year-old Chinese man who originally came in for a drug overdose-related respiratory failure and a fractured hip. With the combined powers of antibiotics, mechanical ventilation, surgery, round-the-clock nursing, and the innate resiliency of the human body, he got better. After an extended stay in the ICU, he was transferred to a medical unit. There he remained in transition limbo for over a year. He was no longer sick enough to be a “patient,” but no facility would take him because he had no health insurance. In essence he was domesticated yet undomiciled.

In between meals and medications, he would be spotted sitting quietly in the chair, looking brittle but never complaining. His toothless smile charmed the nursing staff. The conspicuous absence of any visitors made him mysterious, at least to me. With the passing of time, Mr. C’s facial hair started to grow. He resembled a sage with an overgrown Fu Manchu. Somehow shaving was never mentioned during hand-off, though at some point he expressed his desire to shave.

Amidst the cacophony of acute care hustle and bustle, I chanced upon a scene worthy of a Vermeer painting. A faint mid-day light was breaking through the shutters; a student wearing a blue isolation gown was standing with his back towards the door shaving the patient. A white towel was carefully draped over the patient’s chest and shoulders and half his face was covered with foam. Realizing I was unnoticed, I stood by quietly and observed. With surgical precision and the seriousness of a psychiatrist, the student caressed the patient’s sunken cheeks with a razor, all along keeping a measured conversation, punctuated by the tap, tap, tap of the razor against the side of the basin that was now a hot soup of discarded facial hair and lather. An effusive “thank you” and a bow of approval from the patient concluded the shave.

Returning the next day, I found the patient’s bed occupied by another person. I was told Mr. C. suffered a cardiac arrest overnight and was now in the ICU. There I found him unresponsive and attached to a ventilator. On his clean-shaven cheeks rested the holder of the endotracheal tube. For a few minutes I stared at his “brain dead” state and thought about the still-life scene I witnessed a day before. I recall how he demurred about keeping a “soul patch” just below his lower lip. Now he was surrounded by machines and devices that seemed to rob him of his humanity. The shave the day before was one of his last conscious close encounter with nursing and communion with fellowmen.

The Metaphor of the Shave

Perhaps I am romanticizing the idea that Mr. C’s pre-arrest shave was akin to physical purification, an ablution before his final transition to the unknown. He died the following morning. This episode prompted me to consider shaving patients as a metaphor for nursing itself, at least for patients of a certain gender.

The physical closeness required in shaving someone embodies the nurse-patient relationship, of being with and within reach when we are needed. Shaving brings a semblance of normalcy to the quotidian of life which nursing is meant to restore. Shaving personifies “a.m. care” and inspires gentleness in the caregiver because of the attendant risk of injury. Because shaving takes time and is not considered a priority intervention, it challenges the nurse to organize his or her work flow and make time for it. Making time is one of those competencies that ironically takes time to master.

Perhaps shaving, like bed bath, can be delegated but it would be a missed opportunity for the nurse to bond with the patient. The act has the potential to reveal instead of reduce the patient to a task to be done. Conversation, the essence of nurse-patient rapport, is easily conjured during shaving. It invites the nurse to enter into empathetic discourse that encourages further reflection in both patient and nurse. Ultimately, these reflections may validate the very reasons why we are in nursing.

On various occasions, patients offer to “tip” me for shaving them. A similar response has not been evoked by emptying a bedpan or a commode. Somehow, shaving elicits gallantry in male patients of a certain age. Perhaps it brings them back momentarily to a proud time in their life when they were able to dispense reward to others. Being offered money by a patient, no matter how innocent, stirs professional distress among nurses. A polite refusal is all that is required and inwardly remind oneself that the true reward is simply hearing a patient exclaim that the shave made him “look like a million dollars.”

Notes: The above article is previously published in the American Nurse Today magazine on June 2014 Vol. 9 No. 6. Click on: http://www.americannursetoday.com/article.aspx?id=11628&fid=11574

 

Fidel Lim Photo (2)

Fidelindo Lim, DNP, CCRN

Fidelindo Lim is a clinical faculty at NYU College of Nursing and a per diem nurse educator for NYP Weill Cornell and Hospital for Special Surgery.

Interview with Ian Saludares, MPA, BSN, RN, CCRN

Nurse Leader of North Shore-LIJ Health System, Nurse Manager of Lenox Hill Hospital’s Cardiac Intensive-Care & Cardiac-Telemetry Units, and Treasurer of NYC Men In Nursing

by Ana Cheung, BSN

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Ian Saludares’ Nursing Career

Ian Saludares, MPA, BSN, RN, CCRN, currently leads the cardiac intensive-care and cardiac-telemetry units as Nurse Manager of North Shore LIJ’s Lenox Hill Hospital. His nursing career began in 1994 when he graduated from the University of Santo Tomas in the Philippines with a Bachelor’s Degree in Nursing. University of Santo Tomas is one of the oldest universities in Asia and celebrated its Quadricentennial (400th) Anniversary in 2011. Saludares worked at University of Santo Tomas Hospital until 1999 when he relocated to New York.

Following, he served many years as a Clinical Nurse I at the New York Presbyterian Hospital and registered nurse at St. John’s Riverside Hospital as well as Lawrence Hospital. In May 2011, Saludares earned his Master’s Degree in Public Administration (MPA) with a Concentration for Nurse Leaders from New York University’s Robert F. Wagner Graduate School of Public Services.

In November 2011, he joined the health care team at Lenox Hill Hospital, first serving as an Assistant Nurse Manager within the CCU and Telemetry units before being appointed to Interim Manager and eventually promoted as Nurse Manager. Since 2013, he has also been working as a Nurse Administrator (Per Diem) for New York Presbyterian at The Allen Hospital. Saludares is certified in Critical Care Nursing (CCRN) by the American Association of Critical Care Nurses as well as Advanced Cardiovascular Life Support (ACLS) and Basic Life Support (BLS) by the American Heart Association. Presently, he is preparing to become board certified as a Nurse Executive (NE-BC) by the ANCC – American Nurses Credentialing Center.

Saludares is the treasurer of the NYC Men In Nursing group (also known as the NYC Chapter of the American Assembly for Men in Nursing) and has been a member since the chapter was founded in November 2013. He is also a member of the American Organization of Nurse Executives (AONE), the American Association of Critical Care Nurses (AACN), the Philippine Nurses Association of America (PNAA), and the University of Santo Tomas Nurse Association International (USTNAI). Saludares was interviewed by the American Organization of Nurse Executives in a feature article titled “My Leadership Story” for their September 2011 edition, Voice of Nursing Leadership.

 

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Photo of Ian Saludares with colleagues at North Shore-LIJ May Leadership Gathering (l) and at Nursing Leadership Luncheon (r). Photos courtesy of Ian Saludares.

 

Nurse Leadership Accomplishments for 2014

During this May’s celebration of Nurses Week at North Shore-LIJ, Ian Saludares was presented with the organization’s very first “Distinction In Leadership Award.” He was selected for the award because he “demonstrated leadership that inspired staff to improve patient care; influenced leadership in nursing through innovative approaches and assisted others in their professional development; created a healthy practice environment for all staff; as well as participated in development of aspiring leaders and served as a mentor,” as per the award criteria. Saludares was honored for his achievement in nursing leadership at North Shore-LIJ’s Award Ceremony hosted by the Council for Nursing Recognition and Retention.

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Photo of Saludares and his Nursing Team of 5 East/ 5 Lachman (l) and with colleagues during the Nurses Week Appreciation Breakfast at Lenox Hill Hospital (r). Photos courtesy of Ian Saludares.

Additionally, Saludares’ nursing leadership is reflected in his units’ high nurse engagement scores and patient satisfaction scores. Press Ganey and HCHAPS scores are at an all time high for all nursing sensitive metrics on both of his units. As a result, Saludares was asked to speak at North Shore-LIJ’s annual nursing leadership retreat in May, which was attended by more than 200 nurse leaders from the entire North Shore-LIJ Health System. “I was so proud to share the great and phenomenal work my team from 5 East/ 5 Lachman is doing,” he said. “Receiving my very first standing ovation was exhilarating. I’m confident more than ever that I’m part of a great organization that everyone else will try to emulate. This is just the beginning.”

 

6 Questions for Ian Saludares

What inspired you to become a nurse?

One of the primary reasons I took up nursing was to be able to help my family. During the early 90’s becoming a nurse was one the fastest ways to get to the United States. I am very fortunate that my sister was also taking up nursing at the same time. So we practically saved a lot of money for books and supplies for nursing school by sharing everything. During my 3rd year in nursing school, I realized that I could be really good at this profession and I’m very happy that I still feel the same way about nursing every single day.

How did you choose CCU and Telemetry as your nurse specialties?

As far as I can remember my dad, Leoncio, had heart problems, even when I was very young. When I was in my second year of nursing school, he was hospitalized for a heart attack. My career in nursing started on a very busy medical-surgical floor where I honed my clinical and time management skills. But I was always looking for an opportunity to transfer into the cardiovascular unit (telemetry.) After a year of working on the M/S floor, I was offered the opportunity to transfer to the Cardiovascular Unit at the university hospital I was working at and then eventually moved into the intensive care unit. Since then I have been in critical care all through my nursing career.

You are an amazing nurse leader and have been recognized as such by Lenox Hill Hospital and North Shore-LIJ Health System. You were also featured in the Worldwide Leaders in Healthcare publication and your patient satisfaction scores are through the roof. What can you share with us on what it means to be a leader and how to be a leader in nursing?   

I was very fortunate to be surrounded by amazing nurse leaders and mentors throughout my career. When I started my very first leadership role, I remember asking my nurse mentor, Dr. Reynaldo Rivera, what my top priorities as a new nurse leader should be. This is what he said:
1. BUILD strong relationships
2. Set CLEAR goals
3. It is all about EXECUTION – make things happen.
4. More importantly you need to INSPIRE others.

That’s what I have been doing on a daily basis—making sure I build strong relationships at all levels in every encounter I have. I make sure my entire team has a “shared mental model” by setting clear goals together. Everyone knows what is expected of them, where we are going and how we are going to get there. But more importantly I feel that my main role as their front line leader is to be able to inspire them every day so they are able to do their best work for our patients and their family.

Each year you participate in the American Heart Association’s Heart walk and last year you were the second highest fundraiser for your team. Why is this walk important to you and why should others consider supporting this cause?

This year was the 3rd year I participated in the NYC Heart Walk. The primary reason I participate yearly is to honor the memory of my dad, Leoncio, who died from complications of Cardiovascular Disease (CVD). According to the American Heart Association, Cardiovascular disease is the No. 1 killer of all Americans. In fact, someone dies from CVD every 39 seconds! Heart disease also kills more women than all forms of cancer combined. And congenital cardiovascular defects are the most common cause of infant death from birth defects. I’m hoping next year NYC Men in Nursing members can register as a group and support this cause.

What drew you to join NYC Men In Nursing and what is your role within the organization? 

Joining NYC Men In Nursing is my way of giving back to the nursing profession. I was fortunate to meet nursing leaders and clinicians all throughout my career through the different professional organizations to which I belong. The career path I took was very much influenced by all these wonderful nurses who mentored and guided me. I’m hoping to be able do the same for the younger generations of nurses.

How can joining a professional organization such as NYC Men In Nursing help members who are new nurses and aspiring leaders?

Being part of any professional organization gives you the opportunity to network with other professionals at the chapter or national level. It provides you with a lot of opportunities to learn from others and also opportunities to grow professionally within your career. I encourage everyone to take an active role in local and national professional organizations.

 

Nurses, nursing students and health care professionals interested in learning more about NYC Men In Nursing can visit our Facebook Page, stay up to date with our blog or email us at aamn.nyc@gmail.com for more information. We look forward to seeing you at our next board meeting or upcoming event!

 

NYU_scrubsAna Cheung, BSN

Ana Cheung is a May 2014 graduate of NYU’s Accelerated Baccalaureate Nursing Program and is one of the writers for the NYC Men In Nursing blog. She is interested in medical-surgical and community health nursing, as well as working with geriatric and under-served populations. As a native of Brooklyn, she is committed to serving her fellow New Yorkers.