Never events

http://www.nursingcenter.com/pdf.asp?AID=1100852\

What are they and how do we as front line nurses prevent them?

Interesting concept...needs more studies

Nebulized Heparin in Mechanically Ventilated Patients
Gregory S. Martin, MD, MSc
Authors and Disclosures
Posted: 11/16/2010
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Nebulized Heparin Is Associated With Fewer Days of Mechanical Ventilation in Critically Ill Patients: A Randomized Controlled Trial
Dixon B, Schultz MJ, Smith R, Fink JB, Santamaria JD, Campbell DJCrit Care. 2010;14:R180
Study Summary
Ventilator-induced lung injury (VILI) is an important and relatively common condition among mechanically ventilated patients. Dixon and associates sought to determine if nebulized heparin might improve lung function by reducing pulmonary inflammation and fibrin deposition. This may be particularly important in patients most likely to develop VILI, such as those who require prolonged mechanical ventilation.
The investigators randomly assigned 50 patients who were expected to require mechanical ventilation for > 48 hours to receive either nebulized heparin (25,000 U) or placebo (normal saline) every 4 or 6 hours, depending on patient height, for a maximum of 14 days while mechanically ventilated. They found that nebulized heparin was not associated with any adverse events and did not improve oxygenation. There was no difference in survival, but patients treated with nebulized heparin had more days alive and free of mechanical ventilation (ventilator-free days at day 28: 22.6 vs 18.0, P = .02). On the basis of these results, the investigators concluded that nebulized heparin is associated with fewer days of mechanical ventilation in critically ill patients expected to require prolonged mechanical ventilation, and further trials are required to confirm these findings.
Viewpoint
This randomized clinical trial suggests that nebulized heparin may benefit critically ill mechanically ventilated patients. There are certainly other reports of potentially beneficial effects of anticoagulation in critically ill patients, including the US Food and Drug Administration-approved drug recombinant human activated protein C used to treat severe sepsis. Moreover, heparin use has specifically been associated with improved outcomes in critically ill patients with septic shock. However, little or no data have demonstrated the efficacy of nebulized heparin for mechanically ventilated patients. Although the novelty of this study makes the findings exciting, it also raises more questions about validity and clinical application. At present, there is no reason to be administering nebulized heparin to critically ill patients. As Dixon and associates conclude, these findings require replication to ensure their accuracy. While we wait for more data, how might we judge the veracity of the findings? Could nebulized heparin have truly reduced the duration of mechanical ventilation? One method is to apply specific criteria to strengthen the hopeful cause-and-effect association:
There is a clear temporal relationship, as always in a prospective treatment trial, between the intervention and the outcome;
The strength of the association is reasonably strong, with a 4.6-day (21%) reduction in the duration of mechanical ventilation;
There is biologic plausibility, with mechanistic considerations;
Pre-existing data suggest benefits in other populations;
In a randomized, controlled trial, few other (confounding) variables explain these findings;
No dose-response testing was done to strengthen the relationship; and
Findings have less coherence to existing paradigms on methods to shorten the duration of mechanical ventilation.
Kudos to the investigators for exploring this new world and opening the door to a potential new therapy!
Abstract

CEU review of Anticoagulants

http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=1047254

You asked for it....

For those of you who want to purchase your very own TAMC CCU logo gear I created a shop at cafe press with tee's, sweatshirt etc. You are part of an specially trained few in our organization so if you are as proud of the care we provide as I am, here's your opportunity to show it.

http://www.cafepress.com/TAMCCCU

Mutual Respect is necessary to maintain dialogue. From the moment respect is at risk, the conversation is no longer about getting results and dialogue comes to a screeching halt.
Why? Because respect is like air: if you take it away, it's all people can think about. At that point, the conversation is all about defending dignity.
Use these telltale signs to recognize when respect is at risk during a conversation, and address that issue before trying to resolve the content of the conversation.

• Interruptions
• Pouting
•Name-calling
• Looks of pain, fear, or hurt feelings
• Anger
• Yelling
• Insults
• Threats

CAM ICU assessment

http://docs.google.com/Doc?docid=0Aa1VeiReh57PZGZ4NjZ6cXFfMTU5ejdmc3g0Y2s&hl=en

New Read...

HTN urgency medicine article, peritnent given the volume of patients we have seen with this lately. A real shocker I found as I was reading through the article was this one....who knew?

i.v. nicardipine with i.v. sodium nitroprusside for the treatment of hypertensive emergency in a randomized trial of 40 patients. Significant reductions in SBP and DBP were observed in both groups, with no significant time-dependent differences between groups. Patients randomized to nicardipine had a greater drop in noradrenaline levels compared with patients treated with sodium nitroprusside.
Definetly safer given the thiocy-anate toxicity effects of Nipride.
http://www.medscape.com/viewarticle/715621_2

Newest of the new

And along with the new heart monitors comes the ability to computerize our documentation! So iNet is coming in June. Some new assessment tools will need to be learned~ CAM and MAAS scores instead of Ramsey-check you email for more info on those tools-I'm having issues getting the images to show on here.

just a few images of installation day-we wouldn't have survived without a little therapeutic chocolate.

New Torsdes des Pointes AHA info

http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.109.192704


There is a great table in there with drugs that induce torsades as well as QT and QTC measurements.

Are you thinking of Certification?

http://www.aacn.org/DM/MainPages/CertificationHome.aspx

An optimist is a person who sees a green light everywhere, while a pessimist sees only the red stoplight... The truly wise person is color-blind.
Albert Schweitzer

Happy Holidays to each of you

wishes for you......

• that you come away from each shift feeling that you have made a difference in someone's care.
• that you enjoy, truly enjoy, the people you work with-we may do the job differently but somehow, someway we all came into this to take care of people
• that a patient makes your day in some small way
• that you know you are valued in our unit, our organization but most of all by the community we serve
• that your families know that we appreciate each and every time you come in extra, pick up the phone knowing that it's us asking to give more time to make the team work smoothly
• that we encourage each other to be the best we can be, growth and change are part of the cycle of learning~is your wheel turning?
• that during the holidays you spend time with your families and friends to restore your spirit
• have a Merry Christmas and a Happy New Year!

Precedex for sedation

http://precedex.hospira.com/default.aspx

Please review in light of Diprivan shortage you will probablybe seeing more of this used in the ventilator patients.

Open Chart Reviews

Hey all-Chart reviews-you will find a book with the sheets in it to compete 2 per month along with a chart for you to check off once yours are complete for each RN. There is a reminder chart on the evolving new breakroom door. that resembles the one in the book.

Documentation resource

You are all aware of issues concerning documentation. As we progress toward a totally integrated computer document (the first step is getting the new bedside monitors installed so that they communicate to Powerchart) I feel it is time to reemphasize the content of the infomantion we enter into the chart. This is an excellent site that discusses documentation and legalities. Please take some time to review it-I think you will find it helpful in your everyday practice.






http://www.corexcel.com/html/documentation.title.ceus.htm

H1N1 for professionals

Nurses Air Flu FearsSome are skeptical about the new H1N1 vaccine, while infection control experts work to dispel 'myths'. By Joe Darrah
The debate concerning mandatory flu vaccinations for healthcare workers is likely to intensify as deadlines to receive them are enforced in New York and within various healthcare organizations across the country that are requiring vaccination.
Heated comments at the ADVANCE for Nurses Facebook page reveal a range of views on the topic among nurses, many strongly held. Some have no problem with the mandate and see it as the best way to increase the number of healthcare employees who are vaccinated. However, others express outrage at the idea they are being forced into vaccination, citing their concerns the vaccine can actually cause flu and their belief the mercury used in the shot can be linked to dementia and Alzheimer's. Additionally, many nurses have taken the opportunity to voice these same opinions through letters, phone calls, e-mails and comments at the ADVANCE for Nurses Web site.
"The myth that you can get sick from the flu vaccine is alive and well, and I don't know why," said Bill Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University and president-elect of the National Foundation for Infectious Diseases. "These are the same nurses who go through wonderful scientific training and use scientific principles in everything that they do. So, why would they have particular concern about this scientifically proven [vaccination] as opposed to other science-based treatments they tell their patients to take?"
But where do we draw the line separating myth and fact? How could certain segments of the nursing population believe their health is at risk by receiving the very vaccinations they offer and administer to their patients?
ADVANCE has attempted to get the answers to these questions.
H1N1 Fears
Particular concern recently expressed among nurses surrounds the soon-to-be-available vaccine for H1N1. Specific dates for the release of this vaccination have not been released by CDC officials, but a number of nurses have already contacted ADVANCE expressing fears of getting vaccinated specifically for H1N1 (the CDC has stated the H1N1 vaccine will be separate from the 2009 seasonal vaccination that's now available) because they believe it's being rushed. Many point to deaths reportedly associated with an H1N1 vaccine produced in 1976 - incidences that have been widely documented and refuted by some - as their evidence.
Among them is Melody Bowers Metz, RN, a critical-care nurse working in Ohio. A 2005 nursing graduate, Metz, 52, told ADVANCE she does receive the seasonal shot each year, but has real concerns regarding the H1N1 vaccine.
"In my honest opinion, the government and FDA rushed this through way too fast, and I am very leery about whether it is safe or not," she said. "It takes well over a year for a vaccine to be developed for the upcoming 'next' year and it is thoroughly tested. Those are the concerns that I personally have, and I will not be receiving the H1N1 vaccine."
Schaffner says she and anyone sharing the same sentiments are off base.
"They're just wrong," he said. "H1N1 is nothing new to us. To reach back to one unfortunate episode 33 years ago and say 'for that reason I'll never take flu vaccine' is like saying 'there was a plane crash in 1976; I'll never fly again.' We have 33 years of safety and lives saved, and we made this vaccine just the way we made other ones."
In fact, Schaffner said the regular trivalent seasonal influenza vaccine for 2009 contains killed H1N1 virus.
"I wonder if most know that?" he mused.
Metz told ADVANCE she didn't, but had already received her shot this year, so there's not much she can do.
"Knowing this in advance, no, I would not get the vaccine," she said.
Schaffner blames a lack of education for instances such as these.
"I think people have misunderstandings about flu," he said. "I think the major misunderstanding is this idea that you can know for sure you have it and you can segregate yourself until it's gone. All of our statistics show that doesn't work - that people have mild or asymptomatic illnesses, and that's probably when they're most at risk for spreading it. And that's the point we're trying to get across."
CDC Warnings
Though the CDC provides an abundance of information on the flu, it can come off as confusing, especially when addressing the issue of whether or not flu vaccine can cause illness. Officials clearly indicate the vaccine can cause side effects (beyond allergic reactions) that vary in degree depending on whether one receives the injected or nasal spray form.
While the injection form is made with inactivated virus, the nasal spray does include a live, albeit weakened, form, according to the CDC. Potential side effects to both vaccine varieties include low-grade fever.
So, who's not to say this getting a fever isn't a definition of being "sick?"
Janet Keen, MS, RN, CIC, director of infection prevention and control at Piedmont Hospital, Atlanta, offers clarification.
"A low fever is the body's normal response to making the antibodies that will protect it against flu," she said. "Typically, with influenza, you have a pronounced fever that lasts more than a day. There's a difference between being sick and not feeling well. The risk of acquiring the flu far outweighs the risks of experiencing serious side effects from the vaccination."
This is said to be true even of the nasal form.
Preference vs. Responsibility
"I encourage any nurse who feels uncomfortable with the vaccine to research it, to look at the CDC and other professional literature," Keen said.
At Piedmont Hospital, nursing staff is not currently required to receive either seasonal or H1N1 vaccination, but they're encouraged to, Keen said. She and hospital administrators have also established a mandatory educational program for all employees regarding flu.
"It dispels some of the myths and helps promote compliance with vaccination; and it's really helped," she said.
Concerning the use of mercury in the vaccine, Keen said she "hasn't read compelling literature that supports that."
Schaffner said nurses should weigh their preferences against their responsibilities.
"[Not getting the flu vaccine] is an example where the healthcare worker's interests are being put ahead of the interests of patients, and that's not the tradition of healthcare," he said. "The nurses I've worked with didn't run out of the hospital when we had patients with HIV or SARS or were exposed to anthrax - that's the kind of spirit I want to call forth from nurses and doctors now."
Joe Darrah is senior associate editor at ADVANCE.

Troponin

Troponin-Based Risk Stratification of Patients With Acute Nonmassive Pulmonary Embolism
Systematic Review and Metaanalysis
David Jiménez, MD,
Fernando Uresandi, MD,
Remedios Otero, MD,
José Luis Lobo, MD,
Manuel Monreal, MD,
David Martí, MD,
Javier Zamora, MD,
Alfonso Muriel, MD,
Drahomir Aujesky, MD and
Roger D. Yusen, MD, FCCP
+ Author Affiliations

From the Respiratory Department (Dr. Jiménez), the Cardiology Department (Dr. Martí), and the Biostatistics Unit (Drs. Zamora and Muriel), Ramón y Cajal Hospital, Madrid, Spain; the Respiratory Department (Dr. Uresandi), Cruces Hospital, Bilbao, Spain; the Respiratory Department (Dr. Otero), Virgen del Rocío Hospital, Sevilla, Spain; the Respiratory Department (Dr. Lobo), Txagorritxu Hospital, Vitoria, Spain; the Medicine Department (Dr. Monreal), Germans Trias i Pujol Hospital, Barcelona, Spain; the Division of General Internal Medicine (Dr. Aujesky), University of Lausanne, Lausanne, Switzerland; and the Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences (Dr. Yusen), Washington University School of Medicine, St. Louis, MO.
David Jiménez, MD, Respiratory Department, Ramón y Cajal Hospital, Colmenar Rd, Kilometer 9.100, 28034 Madrid, Spain; e-mail: djc_69_98@yahoo.com
Abstract
Background: Controversy exists regarding the usefulness of troponin testing for the risk stratification of patients with acute pulmonary embolism (PE). We conducted an updated systematic review and a metaanalysis of troponin-based risk stratification of normotensive patients with acute symptomatic PE. The sources of our data were publications listed in Medline and Embase from 1980 through April 2008 and a review of cited references in those publications.
Methods: We included all studies that estimated the relation between troponin levels and the incidence of all-cause mortality in normotensive patients with acute symptomatic PE. Two reviewers independently abstracted data and assessed study quality. From the literature search, 596 publications were screened. Nine studies that consisted of 1,366 normotensive patients with acute symptomatic PE were deemed eligible. Pooled results showed that elevated troponin levels were associated with a 4.26-fold increased odds of overall mortality (95% CI, 2.13 to 8.50; heterogeneity χ2 = 12.64; degrees of freedom = 8; p = 0.125). Summary receiver operating characteristic curve analysis showed a relationship between the sensitivity and specificity of troponin levels to predict overall mortality (Spearman rank correlation coefficient = 0.68; p = 0.046). Pooled likelihood ratios (LRs) were not extreme (negative LR, 0.59 [95% CI, 0.39 to 0.88]; positive LR, 2.26 [95% CI, 1.66 to 3.07]). The Begg rank correlation method did not detect evidence of publication bias.
Conclusions: The results of this metaanalysis indicate that elevated troponin levels do not adequately discern normotensive patients with acute symptomatic PE who are at high risk for death from those who are at low risk for death.
Footnotes
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

New Heparin Reference Standard

Heparin: Change in Reference Standard
Audience: Pharmacists, physicians, hospital risk managers and consumers
[Posted - 10/01/2009] FDA notified healthcare professionals and patients of a change to heparin, effective October 1, 2009, which will include a new reference standard and test method used to determine the potency of the drug and able to detect impurities that may be present in heparin. The change, which will also harmonize the USP unit dose with the WHO International Standard unit dose, will result in approximately a 10% reduction in the potency of the heparin marketed in the United States.
This may have clinical significance in some situations, such as when heparin is administered as a bolus intravenous dose and an immediate anticoagulant effect is clinically important. Healthcare providers should be aware of the decrease in heparin potency as they monitor the anticoagulant effect of the drug; more heparin may be required to achieve and maintain the desired level of anticoagulation in some patients.
There will be simultaneous availability of heparin manufactured to meet the “old” and “new” USP monograph, with potential differences in potency. Products using the new “USP unit” potency definition are anticipated to be available on or after October 8. FDA is working with the manufacturers of heparin to ensure that an appropriate identifier is placed on heparin made under the new USP monograph. Most manufacturers will place an “N” next to the lot number. FDA is also working with the heparin manufacturers to study the impact of this variation in potency and will make the results available when the studies have concluded.
[10/01/2009 - Public Health Alert - FDA]
[10/01/2009 - Information for Consumers - FDA]

Chest Tubes

American Heart for Healthcare Professionals

http://www.americanheart.org/presenter.jhtml?identifier=3052043

All kinds of info on this site for all of us-there is also a section for patients and for home patient caregivers-very nicely done and organized as all AHA materials are.

http://pt.wkhealth.com/pt/re/aha/addcontent.11568289.htm;jsessionid=KSgMjhKL2nyJ0T0G5JpmbJ1TyLpn1k2FfsB26Ykp4KXX2vy5XKJQ!1642465697!181195628!8091!-1
Great article on Drug Eluding Stents on patients with Afib