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Comparison of Outcomes of Combined Thoracic Epidural Anesthesia with General Anesthesia Versus General Anesthesia During Coronary Artery Bypass Graft Surgery
Get PDFCoronary artery bypass graft (CABG) surgery is the most common type of heart surgery in the United States. The main benefit of CABG surgery is a significant decrease in myocardial infarction rate, while the most common complications of CABG are myocardial damage and atrial fibrillation. The incorporation of epidural anesthesia occurred in order to decrease sympathetic nervous system response during CABG but has not been extensively studied. A systematic review was conducted to compare the cardiovascular outcomes of the addition of thoracic epidural anesthesia to the anesthetic plan versus general anesthesia as a solo technique during coronary artery bypass grafting surgery. The PubMed database was searched to identify randomized controlled trials in adult patients undergoing CABG with implementation of thoracic epidural anesthesia versus general anesthesia only. Seven studies involving 668 participants met the criteria. A previously published meta- analysis of randomized controlled trials was also included. The Preferred Reporting Items for Systematic Review (PRISMA) checklist was utilized to extrapolate and synthetize the data. The Critical Appraisal Sheet for Controlled Randomized Studies was adapted from the FRISBE tool in order to compare both within and across the studies. Two outcomes were measured: the degree of cardiac damage that was represented by troponin level and atrial fibrillation rate. The limited evidence suggested that thoracic epidural anesthesia does not provide cardioprotective benefits in adult patients undergoing CABG. The results of the study should be interpreted with caution due to the limited information available and heterogeneity of the studies. The question of whether thoracic epidural anesthesia provides cardioprotective functions requires further investigation. Taking into consideration the results of this study, it is not recommended to use the epidural anesthesia as an adjunct technique on the routine basis during CABG until more information is available
Homecare Nurses\u27 Experiences with Home Telemonitoring Systems
Get PDFTo reduce healthcare costs and to better serve an aging population suffering from chronic disease, advancements in telemedicine like home telemonitoring are being used to improve the effectiveness of outpatient and homecare services. The purpose of this study was to expand upon the telemonitoring qualitative literature to describe home care nurses’ lived experiences with a home telemonitoring program. Separate interviews with four homecare nurses currently employed by a visiting nurse service and working directly with home telemonitoring were conducted. The interviews were analyzed using a phenomenological framework to identify common themes. For these nurses the benefits of home telemonitoring were the same as the ways through which home telemonitoring works. These included early detection of signs and symptoms of disease exacerbation especially for congestive heart failure patients, improved coordination of care, improved disease self-management, and early detection of educational and self-care deficits from frequent contact with the telehealth nurse. Barriers to the effectiveness of telemonitoring included patient anxiety, patient physical or cognitive deficits, and technical limitations of the system. These findings increase the understanding of home telemonitoring from the perspective of nurses involved with its implementation and have implications for future research
Don\u27t be satisfied, identify! Strengthening positive spillover by connecting pro-environmental behaviors to an environmentalist label
Get PDFTheoretically, performing pro-environmental behaviors can lead to positive spillover (increased future pro-environmental behaviors or strengthened environmental attitudes) by increasing someone’s acceptance of an environmental self-identity, or negative spillover by alleviating guilt motivations which fuel some environmental actions. Labeling someone an “environmentalist” in connection to performance of pro-environmental behaviors could strengthen the positive spillover route through emphasizing environmental self-identity rather than guilt reduction. In Study 1, participants perceiving that they performed many pro-environmental behaviors reported greater environmental self-identity strengthening their environmental attitudes, but simultaneously reported a reduction in guilt weakening their environmental attitudes. Since both positive spillover and negative spillover routes were active, there was not a significant total spillover effect from pro-environmental behavior to environmental attitudes. In Study 2, however, labeling those who perceived they performed many pro-environmental behaviors as “environmentalists” led to stronger environmental self-identity with no simultaneous reduction of guilt, increasing the total positive spillover
Computed Tomographic Scans on Patients with Repeat Renal Calculi: A Pilot Study
Get PDFPatients at risk for repeat renal calculi presenting to the ED with symptoms similar to their previous episodes, are likely to be over-exposed to computed tomographic (CT) scans. With recurrence at fifty percent minimizing CT use in this population is imperative (Goertz & Lotterman, 2010). Studies indicate using urinalysis and alternative imaging methods are necessary to prevent increases in radiation exposure, cost and ED visit time. The purpose of the project was to decrease CT use by providing current evidence-based research to ED providers on the overuse of CT scans for patients with a history of renal calculi who present with symptoms comparable to previous episodes. Using the logical model, the project was a retrospective chart review. The study took place in Charlton Memorial Hospital’s ED. Charts were reviewed of patients who had a history of renal calculi and presented to the ED with flank pain. Patients were excluded for age less than eighteen, recent surgery, and chronic renal failure and/or dialysis due to renal impairment at baseline. The pre-presentation chart review was to assess the need to decrease CT scan ordering in the given population. An informational session on current research was provided to the providers and a post presentation chart review was completed to evaluate if there was a subsequent decrease in CT ordering. The study proved using evidence-based research to educate providers could result in a decreased amount of CT scans ordered. CT scans were ordered, eighty percent pre-presentation and decreased to sixty-five percent post
Intra-Operative IV Fluid Management: Goal Directed Therapy with Esophageal Doppler Monitoring vs. Standard Weight Based Fluid Therapy
Get PDFIntravenous fluid management in the peri-operative period continues to be a debate in the anesthesia literature in terms of which fluid type is best along with how much fluid should be given. The majority of post-operative complications in colo-rectal surgery can be traced back to the amount of IV fluids patients receive. Most recently the term Goal- directed therapy (GDT) states that a more individualized approach to fluid management is not only safer but necessary. The Esophageal Doppler, a technology analyzing stroke volume and cardiac output intra-operative, may prove to be a safe way to provide GDT and decrease complications post-operatively. This systematic review examined the impact of the esophageal Doppler versus the traditional weight based fluid management technique on adult (\u3e18 years of age) patient outcomes post-operatively after colo-rectal and abdominal surgery. The goal was to highlight best practices that will decrease adverse patient events and length of stay (LOS). Four out of the five randomized controlled trials analyzed for this review do report that ED use and GDT decrease complications and ICU admissions post-operatively versus utilizing a more standard approach to fluid management. Due to other social variables in discharging subjects, length of stay was not found to be decreased in GDT subject groups. In furthering anesthesia practice, standard fluid management techniques should be updated with a more individualized approach focusing on patient variables such as stroke volume and what the response is to fluid therapy intra-operatively
Understanding the Role and Training of Interdisciplinary Professions: Emergency Medical Technicians
Get PDFUnderstanding the role and training of all healthcare professionals is essential for RNs who are responsible for delegating, receiving, and transferring patient care too. An educational program which educates nursing students about the role, and training of EMTs was designed in an attempt to enhance interprofessional collaboration, communication, and the safe transfer of patients across the two professions. EMTs were selected as a profession of interest related to the acute, and often frantic environment in which RNs and EMTs interact. The purpose of the educational program was to educate program participants related to the role, and training of the varying certifications of EMTs within the New England area. The review of literature examined components of effective communication within healthcare settings, identified patient safety concerns related to ineffective communication, and examined the role and training of varying EMT certifications within the New England area. The educational program utilized an interactive PowerPoint lecture, scenarios, group discussion, and handouts to facilitate learning. Seventeen SNA members from RIC attended the program which was evaluated through the use of a post education evaluation tool. 100% of program attendees completed the voluntary post education surveys. Analysis of post education evaluation tool results, which evaluated attendees interest in program content, presenters’ delivery of content, and the program design where predominantly positive. No participants strongly disagreed with any of the provided Likert scale questions. Educating RNs on the role and training of the varying healthcare professionals they routinely interact, receive, and transfer patient too will decrease communication errors, and improve quality of care
Implications of Extrinsic Cognitive Load on Three Levels of Adult Woodwind Players
Get PDFThe purpose of this study was to examine the effects of two levels of extrinsic cognitive load when three levels of adult woodwind musicians practiced. Extrinsic load was manipulated through repetitive and random practice orders. Participants (N = 43) were novice, intermediate, and advanced university woodwind players who completed a three-day, repeated measures design. At the end of two days of practice, novices who had practiced in a blocked (repetitive) practice order played significantly faster than those who had practiced in a random order. However, this difference was eliminated at 24-hour retention testing. Intermediate players experienced no differential effects of extrinsic cognitive load at the end of practice or at retention. For the advanced players, a trend was found for speed increasing from the end of practice to 24-hour retention (p = .06). While the constructs of cognitive load theory are relevant to woodwind learning, further research is needed to determine effective paradigms for their implementation
Does Prophylactic Antibiotic Administration Time Effect Surgical Site Infection Rates in Colorectal Surgery?
Get PDFColorectal surgery is known for having a high risk of surgical site infection (SSI). Prior research has suggested that administering prophylactic antibiotics prior to colorectal surgery may prevent SSI. This led to the question: In adult surgical patients having colorectal surgeries, does prophylactic antibiotic administration time effect surgical site infection rates within 30 days of surgery? A comprehensive literature review was completed followed by a detailed screening for inclusion and exclusion criteria, resulting in a final total of nine studies. Detailed data were collected for each study, followed by completion of critical appraisal checklists appropriate to the study design. Quality of the evidence was assessed across studies. Six of the studies were cohort studies, with only two randomized controlled trials and one systematic review. Results indicated that there is insufficient evidence to support a definite course of action for timing of antibiotic prophylaxis for colorectal surgery. The certified registered nurse anesthetist (CRNA) should be aware of the recommendations to administer antibiotics for colorectal surgery before the surgical incision based on the results of this systematic review as timing of administration can affect SSI rates. It is recommended to carefully consider antibiotic selection and timing when administering antibiotics for colorectal surgery
Measuring Nurse Satisfaction with the Chest Pain Protocol
Get PDFApproximately 380,000 lives are claimed annually from coronary heart disease. Early identification and prompt action is crucial to preventing mortality. Nurses are the frontline defense to rapidly assessing and intervening to prevent further cardiac damage and alleviate chest pain symptoms. A local community hospital implemented a chest pain protocol for nurses to utilize on the Medical-Surgical units. The chest pain protocol outlines the use of specific medications, including Nitroglycerin sublingually and Morphine intravenously, as well as obtaining an EKG and notifying the provider. The purpose of this project was to measure satisfaction among registered nurses on medical-surgical units at a local community hospital, as it related to the chest pain protocol. A ten-question survey was developed by this author to determine the level of satisfaction among nurses using the newly implemented chest pain protocol. Fifty RNs were surveyed from eight different Medical-Surgical units throughout Kent Hospital. The surveys were deployed approximately 120 days’ post protocol initiation. The surveys were available for completion for one week. Results revealed nurses were neither satisfied nor dissatisfied with the chest pain protocol. Nurses responded favorably that regular feedback regarding the chest pain protocol would have been beneficial to its overall success. Implications for practice were presented and recommendations for future research were identified and included modifying this protocol to be nurse driven and providing further education for nurses at the bedside
World Class(ed) Talk
Get PDFAs American higher education proceeds with the internationalization process of the undergraduate curriculum, college and university campuses continue to advocate for higher levels of study abroad participation among the student population. Originating from a tradition that perceived involvement as a luxury for a select few, these experiences are now commonly viewed as a means for the general student body to develop the knowledge and the 21st century skills required to fully engage the global context in which we live. Despite the continued expansion in the number of students participating, the general profile of participants has remained stubbornly similar, with individuals of “lower” socioeconomic standing and social class origins consistently identified as being underrepresented in these programs.
This investigation aims to better understand this low-income segment of the student population by researching the experience of Pell Grant recipients who did study abroad to determine what factors supported their decision to proceed with participation. The study also seeks to better understand these students’ experience while abroad and upon reentry into their domestic social networks. Employing Seidman’s (2006) structure for in-depth, phenomenological interviewing as a guide, a three-interview series was used to explore the experience of 17 students at a public flagship university in the northeast region of the U.S. Theoretical concepts of social and cultural capital developed by Pierre Bourdieu are utilized to frame the study and to analyze the constructed discourse, as well as to foreground issues of social class and status.
The analysis revealed two groups of low-income participants roughly distinguished by parents’ educational levels and associated social and cultural capital of their families. By examining the discourse of these study abroad alumni, the objective is to produce knowledge that can be used to gain a more robust understanding of these participants to better inform international educators how to encourage and support participation, to expand these opportunities to this population, and to gain deeper insight into how to effectively support them throughout the study abroad process. Recommendations for international educators and further research are suggested