Drug administration errors in anesthesia care settings can range from misreading a drug label, administering incorrect doses and errors made during syringe drug swaps. [2]

Patient safety is vital in all medical care scenarios, but pre-operative, anesthesia delivery, and post-op scenarios are among those that pose the greatest and most significant risks to patients. No one involved in drug administration wants to experience an adverse drug event. 

The efforts in reducing errors in drug administration during anesthesia and throughout post-op care and recovery environments can be divided into three components:

• Enhanced communication goals among staff members
• Improved drug administration management processes
• Innovative, easy to use medical devices

Dealing with the Aspect of Human Error Caused by Overwork

CNRAs and anesthesia teams are among the most overburdened in many care environments and scenarios. Unfortunately, fatigue caused by overwork continues to be one of the primary contributors to human errors in medication administration. Reducing risk factors and errors in drug administration is vital – for the safety of both the healthcare provider and the patient.
 

A study recording fatigue events for anesthesiologists determined that following nine hours of consecutive work, risk for unintentional errors/accidents increased exponentially with every subsequent hour. [3]

A first-year resident is five times more likely to make a prescribing drug error, most likely due to extreme overwork and fatigue and clinical inexperience.[4]

Concerns of fatigue are not limited to the anesthesiologists. CNRAs participate in over 34 million anesthesia procedures in the US alone, with a continued increase of complexity and the number of procedures requiring their support 24/7. This high demand on the CNRA has contributed to sleep deprivation and fatigue, which can have a negative influence on not only performance, but outcomes for the patient. A nurse working longer than a 12.5-hour shift is three times more likely to make some type of error. [5]

Coaching for better communication

Better communication on patient status and any changes in drug administration can be facilitated by efficient updates to charts and databases. Increased collaboration between surgeons, anesthesiologists, and CNRA staff not only influences the ability to enhance anesthesia plan management, but also effects how surgical procedures are managed. The same applies to the anesthesiologists and CNRA’s comprehension of the surgical plan.

Suggestions for enhanced communication: [6]

• Brief “huddles” that aid all-around understanding of both surgical and anesthesia plans with regards to patient care.
• Increased transparency between anesthesia teams and ICU staff.
• Benchmarking CRNA performance (not only regarding patient satisfaction, but also referring to communication with surgeons, OR staff, Post-Op and ICU care teams).
• Attention to detail during an anesthesia hand off. Detailed information in a handoff report should include patient name, surgical procedure, medications given, fluid status, as well as past medical history and allergies. This applies to peri-operative as well as post-operative handoffs. [7]

Improved Procedures for Reducing Risk

A number of protocols and technologies have also aided in the reduction of risks in the field of anesthesia. Among them:

• Color-coded labels – easier identification of drugs. [8] 
• Drug bar code scanning systems – confirmation the right drug is being given.[8] [9]
• Electronic dispensing carts – automated functions and tracking of medications.
• Eliminating the removal of medications from packaging, as well as the discarding of inserts prior to use, and improved protocols in regard to the storage, preparation, documentation, and administration of medications.[9]
• Utilization of controlled “smart” devices – infusions facilitating use of electronic devices that also display a medication library. [9]
• Development of ready-to-use infusions and syringes – along with RFID codes, can be used with automated dispensing cabinets, clear expiration dates, and easier identification. [10]
• Automated information systems – providing up-to-date status and updates to charting. [11]

Some mistakes can be prevented by simply anticipating what can go wrong and then taking steps to prevent those things from happening. Processes and check lists help here.

Attention to detail, enhanced communication, knowledge, and careful planning reduces risks, adverse effects, and enhances patient safety.

Newer Devices Reduce Risk of Error in Drug Administration

One of the major contributors utilized today in reducing drug administration errors is the development of modern devices that provide enhanced usability and comfort for medical stuff already under pressure when conducting IV procedures. For example, more user-friendly designs in manifolds and stopcocks can contribute in efforts to reduce risks in this field, as formerly confusing equipment and devices are exchanges for easy to use options.

Reducing risks and errors in fluid regulation has been the focus of developers, resulting in increasingly advanced devices including Elcam’s SafePort manifold, designed specifically for use in ICU and OR environments, that will be demonstrated at Anesthesiology 2017.

The SafePort manifold is specifically designed for ease of use, offering safe and convenient facilitation in anesthesia and ICU scenarios. The device makes the job of the anesthetists and CRNA easier and safer, with benefits such as:

• Single-handed, simple and comfortable use.
• Dual flow option side port valves, controlled by a simplified 90° turn of the handle.
• Access to multiple IV lines and syringes, as well as delivery by pump. 
• Minimizing risk of inadvertent injections or drug mixtures.
• Assuring zero backflow.
• Eliminating risk of blood loss or gas embolism during disconnection of syringes.
• Facilitating visible control over flow direction and fluid path.

Reducing Complications in Drug Administration

Among the most prevalent hazards in drug administration in pre-operative, operative, post-operative and ICU environments include regulation of intravenous fluids and anesthetic residues found in IV lines. Anesthesia teams are aware that accuracy of flow rates and fluid regulation are essential for patient safety.

Reducing the risk of unintentional administration of residual anesthetics by continuous flushing of the internal valve volume is one of the several benefits of Elcam’s Marvelous^TM stopcock . 

The elimination of post-medication flushing with a syringe also reduces risk of medication interactions and errors.

Reducing the risk of fluid overloads is another risk that can be facilitated by using the Marvelous, via reduction of stopcock manipulations.

CNRAs, anesthetists, ICU staff, and nursing support staff are dedicated to reducing the risk of drug administration errors in dose aspects of patient care. Newer developments in IV, stopcocks, and manifold design are providing positive direction in the reduction of such errors.

Elcam invites you to learn more about SafePort and Marvelous^TM at Anesthsiology 2017. Meeting participants are also welcome to join the raffle  for a pair of SPECTACLES by SNAP Inc. at our booth #3729.

Resources:
1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2933474
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3824420/
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2447555/
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3713658/
5. www.aana.com/newsandjournal/20102019/04call-shift-fatigue-15.pdf
6. https://www.beckersasc.com/anesthesia/5-strategies-to-improve-surgeon-or-communication-with-anesthesiologists.html
7. The Effectiveness of an Anesthesia Handoff Tool: An Electronic Health Record Application to Enhance Patient Safety: Anesthesia eJournal. Vol 4- Issue 1 2016 
8. http://monitor.pubs.asahq.org/article.aspx?articleid=2431681&_ga=2.265776591.1168637975.1507133795-497424936.1507133795
9.  https://www.ppmrrg.com/risk-management/anesthesia-law
10. https://www.pharmedium.com/compounded-services/operating-room-anesthesia/
11. http://drugtopics.modernmedicine.com/drug-topics/news/clinical/hospitalhealth-system-pharmacy/new-technology-enhances-safety-anesthesia-p

Fluid Management
Medicine should be evidence-based, and the discipline of Anesthesia is no exception. While experience and intuition certainly play a role in any practitioner’s decisions, empirical evidence alone cannot be relied upon when making potentially life-threatening or life-saving decisions.
This assertion is at the heart of the argument against “traditional” fluid management, or calculations using the “4/2/1 rule.”¹ Firstly, it is argued that this method relies all too much on estimations and assumptions. For example, preoperative fluid loss is calculated by the anesthesia provider based on an estimation of the time since last oral intake.

Furthermore, estimations of fluid loss during the procedure are made according to the severity of tissue trauma associated with the procedure. Actual fluid loss varies widely from procedure to procedure based upon several factors like patient body habitus, surgical history, and surgical technique. While the traditional method may allow for adjustments with the standard guide of “3 mL of crystalloid for every 1 mL of blood loss,” this is an estimation albeit an educated one.¹ Each estimation made introduces additional room for error.

Evidence pointing out the dangers of this approach can be found in the FEAST trial by Maitland et al. A total of 3141 febrile African children with perfusion impairment were studied in the trial. A 48-hour mortality rate of 10.6% was seen in the patients who received a 20-40 mL/kg bolus of normal saline upon admission, versus a 7.3% 48-hour mortality rate in the control group of patients who received no bolus.²

While the hazards of overly-restrictive fluid management are well-known and understood, giving too much fluid can be equally hazardous. Fluid management should be precise and must be backed by clinical evidence. As a paper in Clinics in Colon and Rectal Surgery stated, “Traditional methods of perioperative fluid management have emphasized a liberal approach to administration of fluids. Those traditional methods have now been called into question.“ This paper looked at a total of seven randomized trials that examined the effects of perioperative fluid restriction on patient outcomes. Although there were conflicting results, the majority of the trials found that restrictive fluid strategies were associated with better results.³

So what does this all mean for today’s anesthetist and CRNA? Modern fluid management equipment can actually make the job easier and less stressful as the contemporary methods of fluid maintenance do not rely on estimation.

In fact, one accurate tool for fluid management decisions endorsed by the National Health Service of the UK, esophageal Doppler monitoring (EDM), has shown promising results. Kuper et al. compared 658 major surgical procedures without EDM to 649 major procedures using EDM at three large English hospitals. They found “a 3.7 day reduction in total length of stay. Length of stay was reduced at each site, and in most specialities.”⁴

In summary, providing fluids in the anesthetic setting based on estimations or even general rules is proving to be less reliable. Rather, fluids should be given based on physiologic need and in pursuit of a specific improvement in patient condition, using up-to-date equipment. This does not mean that patients undergoing major procedures or in critical condition should not be monitored closely, it basically takes the practice of assumptions out of fluid management and relieves some stress from anesthesia personnel.

Infection Prevention
It is the responsibility of all operating room personnel, from surgeons to anesthetists, from CRNAs to surgical technologists, to make every effort to prevent infection opportunities. Unfortunately, it would appear that a potential source of contamination is often neglected – the ventilator.

According to a 2012 paper by Zingg et al., in one randomized trial the ventilator was the second most common infection origin. The most likely explanation was that the ventilator was contaminated by the gloved hands of anesthesia personnel and the contamination was then transferred to the next patient.⁵

The authors acknowledge that anesthesia providers already frequently wash their hands and almost constantly wear gloves in patient interactions.⁵ However, an additional infection-prevention measure can be adopted by the use of modern stopcocks, like the Marvelous . The Luer-activated valve in this stopcock acts as a barrier to bacteria, eliminating the need to open the line to access it. The constant flushing of the side port with (main line) carrier fluid that minimizes dead space and prevents stagnation, can further reduce the risk of bacterial colonization.  The Marvelous further improves patient safety by the constant flushing of the internal valve volume. This feature assures complete rinsing of drugs from the system thereby reducing the chance of drug interactions and unintentional administration of residual drugs.

References
1. Stoelting, R.K. et al. Basics of Anesthesia, 5th ed. Elsevier, 2007; p. 349.
2. Maitland, K. et al. “Mortality after Fluid Bolus in African Children with Severe Infection.” NEJM. June 2011, 364(26);p.2483-2495. http://www.nejm.org/doi/pdf/10.1056/NEJMoa1101549
3. Bamboat, Z.M. et al. “Perioperative Fluid Management.” Clin Colon Rectal Surg. Feb 2009, 22(1);p.28-33. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780230/
4. Kuper, M. et al. “Intraoperative fluid management guided by oesophageal Doppler monitoring.” BMJ. May 2011, 342;d3016. http://www.bmj.com/content/342/bmj.d3016.short
5. Zingg, W. et al. “Stopcock Contamination: The Source Does Not Explain It All.” Anesthesia & Analgesia. June 2012, 114(6);p.1151-1152. http://journals.lww.com/anesthesia-analgesia/Fulltext/2012/06000/Stopcock_Contamination___The_Source_Does_Not.3.aspx

The following CDC statistics illustrate how this problem is growing:

• More than one-third (36.5%) of US adults have obesity
• Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death
• The estimated annual medical cost of obesity in the U.S. was $147 billion U.S. dollars in 2008 (Incenta health published a figure of $190.2 billion in 2015); the medical costs for people who are obese were $1,429 higher than those of normal weight, (according to Incenta Health this is 36% higher)

Nurses and doctors are making adjustments to procedures to accommodate obese individuals, but it is increasingly clear that the standard tools and techniques might not be enough. In anesthesia there are specific challenges when the patient due to undergo surgery is obese.

The Known Risks of Administering Anesthesia to Obese Patients

Being overweight, and especially obese, puts an individual at a higher risk when undergoing surgery – with one of the primary concerns being the administration of anesthesia.

The known risks include:

• Difficulty in locating veins for intravenous medication
• Determining a proper medication dose relative to body size
• Ensuring proper oxygen and airflow before, during, and after surgery
• Taking more time to regain consciousness
• Intubation

Anesthesia Options for Obese Patients

During the preoperative assessment, health practitioners will create a tailored plan for each patient regarding anesthetic management. At this point, it may be determined that additional measures are required to safely and effectively administer anesthesia to the patient.

The preoperative assessment includes:

• Airway assessment
• Mallampati score
• Thyromental distance (TMD)
• Respiratory and oxygenation status
• Snoring, tiredness, observed apnea, and high blood pressure with BMI, age, and neck circumference (STOP-BANG)
• Cardiovascular system assessments
• Patient transportation planning

The chances of multiple measures being determined upon is higher when the patient is obese.

Multimodal Approach

It is recommended to take a multimodal approach to improving patient outcome, and perioperative epidural anesthesia (EDA) is often essential to prevent from relying exclusively on opioid administration for anesthesia. While the subject is still up for debate, one recent study found that EDA improved postoperative vital capacity, lung volumes, and other spirometric values quicker than patients who were treated with opioids.

Due to the lack of palpable bony landmarks and the depth of space in the fatty tissue of an obese patient, a multimodal analgesic approach is often more practical. This might include the use of opioids, acetaminophen, NSAIDs, and local anesthetic.

Postoperative Considerations for Obese Patients

Unless the patient has any ongoing medical conditions other than obesity, or underwent major surgery, they are usually nursed on the surgical floors following a complication-free surgery. However, extra precautions might still be necessary. For example, obese individuals who use a CPAP machine at home will benefit from a postoperative CPAP.

Maintaining safe IV connections can be a challenge in obese patients. Also, these patients may require more intravenous medication because intramuscular injections often are not a viable option in morbidly obese individuals.

This is where the Marvelous Stopcock and Safe2 Rotator acan ve useful. They can prevent disconnections and ensure medication is properly flushed – plus they keep nurses safer by preventing needle sticks.
 

Learn more about Marvelous Stopcock.

Source:
https://www.cdc.gov/obesity/data/adult.html
https://www.asahq.org/whensecondscount/patients%20home/preparing%20for%20surgery/surgery%20risks/obesity%20and%20anesthesia
http://ceaccp.oxfordjournals.org/content/8/5/151.full

Before Intubation Challenge – Airway (and Patient) Resistance

One of the most common intubation challenges for CRNAs is intubating a patient that is obese. Excess body mass, and especially additional soft tissue in the upper airway, increases airway resistance.

In many cases, the CRNA will need to position the patient slightly upright to shift the abdominal contents away from the diaphragm. This will reduce the pressure around the airway, making it easier to insert the tube, as well as ensuring proper ventilation while the patient is intubated.

A similar situation arises when patients simply have a narrow airway. In this case, CRNAs sometimes struggle to see if the tube is inserted correctly. Whenever this happens, the CRNA is usually required to ask for a second opinion to verify that the tube is placed properly, and in special circumstances, an X-ray can be performed to confirm proper placement.

Intubation Innovations

The ideal situation would be to have a small, lighted camera on the end of the Laryngoscope. This would improve accuracy and save the need for an X-ray to confirm the placement. The companies Infinium and Covidien (Medtronic) are only two of the companies that offer such a product. Verathon’s Glidoscope is even available on Ebay. Video Laryngoscopy and fiberoptics were documented as assisting tracheal intubation. You can read more about this case in the Medscape website.

As tracheal intubations are always a challenge, various developments of intubating devices are emerging in an effort to resolve the issue or at least make intubation a bit easier for medical staff. The MK intubating Airway claims that while standard procedure is maintained the new rigid, non-crushable conduit and bite guard improved on long standing airways that provide limited functionality by permitting removal of the airway without disturbing a placed bronchoscope. Another device still under development, the Esophocclude can be used to prevent pulmonary aspiration (yet another challenge of intubation). The Esophocclude is an encapsulated self-expanding stent that resembles a pill,  which is intended to be swallowed by patients before intubation. It expands and prevents the flow of gastric acids into the lungs.

New in Intubation Training

Swansea innovations have developed a unique training device for CRNAs as a means of improving the psychomotor skills involved in the manipulation of a fibreoptic endoscope, which today is considered a necessary skill in the anesthesia arsenal. The C-MAC Tip system from Karl Storz Endoscopy-America, Inc. is a great teaching tool, allowing learners to perform direct laryngoscopy while providing reassuring visualization to the instructor of the intubation on the screen.

Code Blue

The most common situation for ICU nurses that makes intubation challenging is during a Code Blue when a patient is thrashing around. It’s virtually impossible to insert the tube alone and this scenario requires collaboration between the team of nurses to restrain the patient before intubating. It would be great if nurses had some type of vest they could quickly toss over a patient and attach to the bed to restrain their upper body so they could start intubation with less people. Innovative spirit is demonstrated once more as a team led by Spectrum Health Innovations created a device to prevent self-extubation. The new approach led to the design of a retaining block to keep the tube in place. The block is held in place by headgear modeled after a scuba mask.

During Intubation – Monitoring is Key

While the patient is intubated, the vast majority of problems are easily prevented by an attentive CRNA who is monitoring their patient. The CRNA performs regular vital signs’ monitoring during anesthesia to ensure the patient remains in a healthy, stable state at all times. They also ensure proper airway management and anesthesia management throughout the procedure.

After Intubation Challenge – Sedative Weening and Patient Awakening

Following a procedure, a CRNA or ICU nurse will start the process of weening the patient off of their sedative. During this time, it’s critical to monitor sedation levels so a patient doesn’t wake up on their own and start choking on the tube.

Once the sedative has mostly worn off, the CRNA or ICU nurse removes the tube and briefly wake the patient to confirm that the patient can breathe on their own. If the patient needs to remain intubated because they won’t be able to breathe on their own, a nurse will be there when the patient wakes up to explain why they are intubated and how important it is for them to remain intubated.

A common problem in the ICU is when the floor is understaffed and all of the nurses get so busy that they don’t notice a patient is waking up from their sedative. This is an example of where telemedicine can help. Having an extra set of eyes on patients increases the level of care patients receive without requiring more nurses on duty.

It’s imperative for ICU nurses to continually monitor sedation levels, vital signs, and to be in the room when the patient wakes up to explain where they are and why they are intubated. If the patient isn’t restrained, they will often panic and remove the tube.

Even in scenarios where patients are restrained, they still find ways to get past restraints and remove their tube. This is a nightmare for ICU nurses because, during their state of panic, patients often end up disconnecting IVs and other tubing.

This is when innovative medical devices like the Safe2 Rotator are especially useful. The Safe2 Rotator has a luer lock connection that prevents disconnections when a patient pulls at tubing or moves around erratically.

If for whatever reason a patient does wake up while intubated, the Safe2 Rotator can help ensure they are still receiving the medications they need until a nurse can get to them and get them properly intubated again.

Daily challenges continue to be faced by ICU nurses and CRNAs, but technology and innovations are not far behind, assisting medical staff in giving enhanced patient care, while keeping staff and patients safe.

Sources:

• https://www.ukessays.com/essays/ nursing/assisting-in- endotracheal -intubation-nursing-essay.php
• https://ccforum.biomedcentral.com /articles/10.1186/cc13776
• https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3375171/
• https://www.ems1.com/ems-products/ medical-equipment/airway-management/articles/ 1957214-How-to-improve-airway-control-for-obese-patients/
• http://emedicine.medscape.com/ article/110880-overview
• http://www.medtronic.com/covidien/ products/intubation/ mcgrath-mac-enhanced -direct-laryngoscope
• http://www.infiniummedical.com/ camera-laryngoscope
• http://www.rehabmart.com/ category/ patient_restraints.htm
• http://innovations.clevelandclinic.org/ Technology/Invention-Catalog/ Medical-Devices/ Inventions/ MK-Intubating-Airway.aspx
• http://healthbeat.spectrumhealth.org/% E2%80% A2intubation-innovations/
• http://www.innovation.pitt.edu/ innovations/ esophocclude/
• http://www.mdedge.com/ emed-journal/article/ 100638/imaging/ tech-tools-innovative-devices-ed

What is Telemedicine?

According to the American Telemedicine Association, telemedicine is “the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status.” The first documented study of telemedicine in the ICU was conducted 25 years ago where telemedicine consultations were used to assist with the care of 395 patients in the ICU of a 100-bed hospital. The study found that telemedicine improved patient care and television consultations had a greater clinical impact than telephone consultations.

The way this works is that a tele-ICU system staffed with critical care nurses, nurse practitioners, physician assistants, and additional support staff operates 24/7 on-call. Each tele-ICU registered nurse (eRN) is typically responsible for 30 to 40 patients. There are currently around 45 tele-ICUs in the U.S. that connect over 200 hospitals with more than 6,000 beds.

How Nurses Are Responding to the Rise of Telemedicine in the ICU

According to an online survey of over 1,200 nurses from the American Journal of Critical Care, around 79% of nurses believe that tele-ICU systems improve patient care and about 75% believe it improves job performance. The feedback from nurses overall has been very supportive and encouraging, which demonstrates a clear need for telemedicine in the ICU.

Feedback on telemedicine from ICU nurses:

• 66% found improvements in collaboration
• 63% saw increased speed in work performance
• 60% noted improvements in communication
• 60% saw improvement in nursing assessments

However, not all of the survey findings were positive. The most significant barriers for telemedicine include staff attitudes towards telemedicine, technical difficulties with audio and video, and a lingering belief among some nurses that telemedicine actually interferes with patient care.

While there are still issues that need addressing, telemedicine is here to stay and we expect it to continue to improve patient care and provide greater opportunities for nurses with diverse skill sets.

The Biggest Benefit: Applying Multiple Specialties and Skills at Once

Nurses have always had a critical role in hospitals – assessing vital signs, administering medication, providing emotional support, and being the go-to person patients count on for virtually everything during their hospital stay. Today, hospitals want nurses to expand their skills and expertise even more.

The biggest benefit of telemedicine in the ICU is the ability to have so many nurses with different specialties and backgrounds on-call at all times. Tele-ICU systems provide a second set of eyes with a possibly different point of view, allowing patients to get better care without having to wait on the schedules of multiple specialists to line up perfectly.

As a nurse with specialized skills, telemedicine also expands your career opportunities. Many nurses love helping patients and find it too rewarding to walk away from, but they cannot always stay in the hospital environment for one reason or another. Telemedicine gives nurses the chance to do the work they love without having to deal with some of the things they don’t enjoy when working inside a hospital.

Source:
http://ccn.aacnjournals.org/content/30/4/46
http://journals.lww.com/ccmjournal/abstract/1982/07000/telemedicine_in_critical_care__problems_in_design,.14.aspx
http://ajcc.aacnjournals.org/content/25/1/e14.full
http://www.healthcareitnews.com/news/telemedicine-improves-patient-care-outcomes-icu-nurses-say

International Nurses Day is here again and we want to take the time to shed light on what makes nurses so valuable to hospitals and their communities.

The Role of Nurses in the Hospital

Nurses affect human lives by the very nature of their profession, nurses are the backbone of hospitals.

One of the most important role of the nurse in a hospital is that of a patient advocate. Nurses spend more time with patients than their doctors do. Often nurses might have to step in and advise the doctor to take a different approach due to the unique circumstances of their patient. Without nurses, patients would not be able to receive the quality of care at the scale that is necessary for hospitals to care for large groups of people at once.

Many nurses dedicate their careers to specializing in specific practice areas or skill sets (e.g. ICU, CRNA) that make them an invaluable asset to any medical team. These nurses comprise multidisciplinary teams that care for patients with complex disorders that require a wide breadth of specialized knowledge and experience.

Nurses are also the eyes and ears of the hospital. They know which healthcare products work best, they refine the processes for patient care, and they identify excessive waste and other inefficiencies.

In fact, all Elcam Safety products are inspired by nurses who want to improve the healthcare environment for patients and staff. For example, the Marvelous Stopcock,  which is designed to improve the safety of the patients by reducing risks of bloodstream infections and drug residues, and the staff safety concerning blood and drug spills and needle stick injuries.

How Nurses Can Positively Impact Their Communities

Nurses take on challenges that extend beyond the hospital doors. According to the International Council of Nurses, there are 17 sustainable development goals of modern nurses, for example:

• No poverty, no hunger
• Improved nutrition, clean water and sanitation
• Good health and well-being
• Quality education
• Gender equality and reduced inequalities
• Decent work and sustainable economic growth

(See the complete list here )

That might sound idealistic, but there are very practical ways nurses do impact their communities and work towards achieving these goals.

Here are 5 examples of how nurses improve their communities:

• Providing the same quality of care to rich and poor patients
• Treating male and female patients equally
• Educating patients on proper hygiene, optimal nutrition, and overall health practices
• Providing birth control education to young women
• Collaborating within hospital systems and the legislative system to improve the nursing profession

Great nurses love people and have the ability to influence others in a way that sticks with them long after they leave the hospital.

How Nurses Can Become Better Leaders

It has become apparent that nurses must understand the true value they provide and to make their voices heard. Part of spreading their message more effectively is becoming a better leader.

The first step to becoming a better leader as a nurse is advancing your education and growing your expertise. The more knowledge and skill you possess, the more you can contribute. Certifications and other advanced learning courses are great options for registered nurses.

The other crucial step is getting more involved in leadership roles in hospitals and other medical organizations. Nurses have an incredible point of view that other healthcare leaders need to hear and learn from. To create change, nurses must be proactive and challenge the current standards.

At Elcam, we aim to improve healthcare by equipping nurses and other staff members with safe, more effective medical devices. However, it would not be possible for us to supply so many hospitals without the approval and recommendation of the nurses who use our products .

Nurses affect human lives by the very nature of their profession. In the ICU and as CRNAs this is even more so due to the high pressured nature of these departments and the complex conditions of the patients. Nurses have an impact, wherever they go, inside and outside the hospital. On May 12th, we should all celebrate nurses and their dedication to people.

Source:

• http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-fact-sheet
• http://www.nursetogether.com/6-roles-nurses-play-truly-make-them-heart-healthcare
• http://www.icn.ch/images/stories/ documents/ publications/ind/ ICN AVoice ToLead guidancePack EN Lowres.pdf
• https://www.theatlantic.com/health/archive /2016/02/ nursing-shortage/459741/
• https://www.nursingtimes.net/roles/nurse-managers/nhs-to-face-chronic nurse shortage by-2016/5059871.article
• http://www.telegraph.co.uk/news/2017/01/ 19/96-per-cent-hospitals-have nurse shortages-official-figures/
• http://www.toprntobsn.com/countries-most-in-need-of-nurses/

In fact, around two-thirds of ICU beds are occupied by patients who are 65 years or older. As a result, meeting the needs of elderly patients is a top concern for nurses in the ICU. This blog is a short review of the major needs of elderly patients in the ICU.

The Importance of Geriatric Experience

The growing population of elderly adults in the ICU challenges hospitals to adapt their care services. Hospitals are focusing more effort on building teams of care providers who have experience with elderly patients. Ideally, these teams include nurses, a geriatrician, an intensivist, and a physical therapist, among other specialized care providers as required.

Preventing and Treating Sepsis

Sepsis is one of the top five most common admitting diagnoses for elderly patients in the ICU. Among elderly patients who survive sepsis, research has shown that 76% were less likely to return home after being discharged from the hospital – requiring additional care from skilled nursing homes and similar facilities.

Nurses can lower mortality rates among elderly patients with sepsis by identifying and managing sepsis in the early stages of the patient’s stay in the ICU. Methods for identifying sepsis include screening for sources of infection, identifying chronic conditions, screening for functional decline, and monitoring subtle changes in mental status.

Overcoming Delirium

Many patients experience delirium in the ICU, and unfortunately, elderly patients are at a high risk of delirium. In a study of older adults admitted to medical ICUs, researchers found that 62% of patients had evidence of delirium during their stay. Others studies have found rates as high as 70% to 80%.

Traditional mental status evaluation methods, such as the Glasgow Coma Scale and Ramsay Scale are effective for measuring wakefulness and arousal, but they do not provide insight into the patient’s state of mind. On the other hand, the confusion assessment method for the ICU (CAM-ICU) has proven effective and reliable for assessing a patient’s mental state.

Delirium is difficult to track in the ICU because patients are often sedated and intubated, and we currently lack the proper tools to monitor delirium without communicating with the patient. However, the recognition of delirium is important because it typically prolongs the patient’s hospital stay, increases short-term mortality, and raises costs in the ICU.

Preventing Disconnections and Misconnections
Since elderly ICU patients are prone to delirium, they sometimes forget they are in the hospital and have an adverse reaction to all of the sounds surrounding them and the tubes connected to them. As a result, the patient may accidentally (or intentionally) disconnect their IVs by pulling the tubes apart or attempting to get out of bed.

To avoid such instances, the Safe2 Rotator has a unique spinning lock that helps prevent tubing disconnections and consequential misconnection.

In order for elderly patients to get the care they need and to recover smoothly, they need consistent delivering of medication. The Safe2 Rotator and the Marvelous stopcock that uses a luer activated design and a circumferential inner channel also result in improved infection control and reduction of medication errors.

Keeping Elderly ICU Patients Safe

As more and more elderly patients require treatment in the ICU, it becomes more important to raise awareness to the special concerns of treating these patients. With such awareness, both patient safety and staff safety can be enhanced.

Learn more about Elcam Products for the ICU.

Recommended further reading:

• Learn more about Sepsis management and treatment
• Learn more about potential causes of sepsis
• Learn more about disconnections and patient safety

Resources

• http://www.medscape.org/viewarticle/459082
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3224497/
• https://www.researchgate.net/publication/230599355_Management_of_Delirium_in_Critically_Ill_Older_Adults
• http://ohiohospitals.org/OHA/media/Images/Patient%20Safety%20and%20Quality/Documents/Sepsis/Older-Adult-Exp-Englert.pdf

Elcam was proud to be among the companies displaying at this important event this year. Our presence at EfCNNa is a great opportunity for Elcam not only to present our products to users but also to receive their important feedback in order to learn more about the needs of ICU nurses in the field. This blog is a short summary of what we have learned at the conference and the topics we felt were most discussed.

Sepsis and Awareness to Infection

A poster published by University Hospital of Bratsilava, Hospital Ruzinov ICU- Bratislava, Saint Elizabeth College of Health and Social Work in Bratislava, reviewed sepsis as a serious problem for nursing staff. The treatment of sepsis takes place mostly in the ICU and consist of antibiotics administration and surgical removal of the sepsis bearing area (if required). Treatment is given by regular and specialized nurses. The prognosis is not a good one, with mortality rates not decreasing in the last decade and remaining at 60%. Stijn Blot claimed in his talk that 30% of HAIs can be prevented. He called for high awareness as a means to prevent infection. With sepsis being caused in many cases by other, more localized infections, this is an interesting point that needs to be reviewed further.

  
The poster recommends nurses to be educated in the latest sepsis care methods. We recommend that you take a look at our blog regarding Early Goal Directed Therapy, which is known to assist in sepsis management.

Nursing Workload

A poster published by the School of Nursing in Sao Paulo, Brazil reviews the nurses’ workload in Brazilian hospitals between the years 2012 (Sept-Dec) and 2016 (June-August). The study authors Elaine Machado de Oliveira, Silvia Regina Secoli and Katia Grillo Padilha, used the Nursing Activities Score (NAS) as a tool to estimate nursing workload in 8 ICU departments in Brazil. The poster shows data to support that both the nursing workload and the risk of mortality have increased in Brazilian ICUs. The study is important to adjust nursing professionals according to workload and severity of patients’ conditions. The graphs in the poster indicate interesting finds; the first is that there is a negative correlation between nurses’ workload and the quality of treatment.  Another find is that patients who come to the ICU after surgery increase the workload of critical nurses. Both these findings were supported by lectures presented at the conference.

 
An interesting find regarding nurse workload and patient care in the ICU was presented in a lecture by the Karolinska University Hospital. It showed that although the patient/ nurse ratio is reduced, so is the length if the ICU stay. No difference in ICU mortality could be found with relation to nurse workload. Its obvious nursing workload is increasing but its effect is not all negative. Elcam Marvelous helps nurses to complete their duties faster, take a look at his infographic to learn how Marvelous saves nurses time.

Double check for High Risk Medication

A poster published by MPH Galilee Medical center discusses the implementation of a procedure for double checking high risk medication administration in ICU general and evaluating its efficiency. The results corroborate the assumption that practicing correct independent double checking, supervision, real-time feedback and reflective debriefing after each error report are among the components important to efficient implementation and reducing medication administration errors. Read more about working with high risk materials and their safe administration.

Adverse Events, Nurses’ Workload and Patient Condition Severity

In a lecture regarding adverse events, presented by the Catholic University of Portugal and UNESP, a claim was made that 50% of adverse events could be prevented. A study was presented correlating patient condition severity, nurses’ workload and adverse events. Results show a positive correlation between adverse events and patient severity but a negative correlation between nurse workload and adverse events. At first these result seem to contradict other studies previously published in this area, but they are explained by improved ICU staff management and dimensioning.

Although patient condition severity is predictive of adverse event probability of occurrence, patient condition severity (as demonstrated by admission type) is not predictive of the actual workload of nurses during the first day of ICU stay (despite ICU nurses’ conceptions and expectation to the contrary). This was proven in a study presented by students from the School of Nursing in the University of Sao Paulo, Brazil.

Participants who have login credentials can download the abstract book of the conference.

At Elcam we believe that education of medical staff is important to improving patient care. Part of this education is developing nurses’ awareness to using improved tools and safer equipment in the ICU and at the hospital in general.  We believe this is very important to improving patient care, while also ensuring staff safety and this is what we strive to do with our line of Safety products.

Resources:
http://www.efccna.org/about/objectives
http://www.efccna.org/congress2017
https://www.linkedin.com/in/stijn-blot-456ba51/

Risk Factors

There are several risk factors that can lead to the development of CPSP. While we still lack thorough research to form a clear consensus on each risk factor, there is enough evidence to show a correlation between the following risk factors and CPSP.

Below are some of the known risk factors that occur before, during, and after surgery:

• Pre-existing pain syndromes such as low back pain, fibromyalgia, migraines, etc. (pre-operative)
• Lack of resilience and other similar psychological factors (pre-operative)
• Pre-operative pain in surgical site (pre-operative)
• Younger age and genetic components (pre-operative)
• Type of incision (intra-operative)
• Type of surgery (intra-operative)
• Nerve handling and injury (intra-operative)
• Use of chemotherapy or radiotherapy (post-operative)
• Disease recurrence at surgical site (post-operative)
• Acute post-operative pain (post-operative)

Although CPSP is not the single cause of the epidemic of opioid abuse in America, the two issues are related. Over 95% of patients are prescribed opioids following inpatient and outpatient surgical procedures. Of those patients who receive opioids following surgery, around 8% continue taking opioids one year following low-risk surgery and one in 15 of all surgical patients who receive opioids become long-term opioid users.

Preventive Strategies

While there are ways to improve post-surgical pain management, the ideal approach is to prevent CPSP from occurring in the first place. A crucial preventative measure that is less common is avoiding the surgical procedure and seeking an alternative solution. However, this is not an option in many cases.

One of the most critical preventative measures is preventing nerve injury during surgery through the use of nerve-sparing techniques. Once a nerve is damaged, it triggers a sequence of inflammatory neuropathic mechanisms throughout the body. This variety of mechanisms makes it virtually impossible to manage all of the pain through a single therapeutic method or strategy.

Proper documentation is perhaps the best preventative measure that sometimes gets lost in the shuffle of surgery. Once a patient arrives in the ICU following surgery, the ICU nurses rely on the anesthesiologist’s documentation to form their pain management strategy. Sometimes an anesthesiologist will complete a patient’s chart pre-operation and then make slight adjustments to the patient’s sedation or pain management during surgery without updating the patient’s chart. Other details affecting the patient’s pain also might not make it to the patient’s chart, giving the ICU nurses inadequate information to work from.

Nurses’ Role in Pain Management

Communication between anesthesia and the ICU nurses is an important step in effective post-operative pain management. It’s much easier to prevent CPSP by ensuring pain is well-managed throughout the patient’s entire hospital stay. Once the pain passes a certain threshold, which is subjective to each patient, more medication is often required to lower that pain back to a tolerable level than would have been necessary to prevent the pain from reaching that threshold in the first place.

Effective management of the transfer procedure of patients from anesthesia to ICU following surgery is key to ICU pain management plans, thus enhancing the quality of care for patients. ICU nurses and CRNAs can do something for their patients by cooperating for improved communications between their respective departments, for effective pain management throughout the patients’ hospitalization period.

Elcam Medical helps ICU nurses and CRNAs manage pain more effectively through the use of innovative medical devices, such as the Marvelous Stopcock and Safe2 Rotator. These devices allow nurses to administer sedatives and pain medications through a needle-free injection site while preventing disconnections and air embolism.

Learn more about Elcam Safety’s Marvelous Stopcock and Safe2 Rotator.

Resources

• http://www.anesthesiallc.com/publications/blog/entry/an-anesthesiologist-led-approach-to-the-silent-epidemic-of-chronic-postsurgical-pain
• http://www.anesthesiallc.com/publications/anesthesia-industry-ealerts/970-an-anesthesiologist-led-approach-to-the-silent-epidemic-of-chronic-postsurgical-pain
• http://pain-focus.com/chronic-postsurgical-pain-prevention-management/
• http://emedicine.medscape.com/article/1268467-overview
• http://finance.yahoo.com/news/somnia-anesthesia-hosts-crna-contest-150000628.html
• http://www.aana.com/newsandjournal/nnaw/Pages/default.aspx

As a result, trends in critical care are among the hottest topics in the healthcare industry. With the 7^th EfCCNa conference just around the corner, we want to highlight some of the trends up for discussion.

EfCCNa Congress 2017 in Belfast

EfCCNa is one of the world’s leading conferences for critical care nursing. The 2017 conference is located at the award-winning Belfast Waterfront Hall in Northern Ireland between February 15^th and 18^th.

Among other experts in the field of nursing, the conference begins with a keynote presentation from Dr. Paul Fallbrook – the President of the World Federation of Critical Care Nurses, a Professor of Nursing at the Australian Catholic University, and Nursing Director of Research at The Prince Charles Hospital in Brisbane, Australia.

The following are a few of the workshops closely related to trends in critical care that look interesting and useful.

Caring for a Child in Adult ICU

Although not as common in many hospitals, there are circumstances where a child ends up in the adult ICU. In these cases, the nursing staff has to make adjustments from the protocols they commonly use to protocols that are better suited for children.

The objectives of this workshop include:

• Providing adult ICU nurses with an understanding of the differences in nursing critically ill children
• Highlighting physiological and developmental differences in children that require alternative approaches, drug and fluid therapies, drug dosing, resuscitation and safety issues
• Explaining the different roles of the family in critically ill children

The two specific scenarios up for discussion are based around a couple of the most common cases – a 12-year-old head trauma child and a two-year-old child with respiratory failure.

Manual Hyperinflation

Manual hyperinflation is a useful maneuver that nurses can apply to mimic a cough in the patient, which mobilizes secretions for removal and clears the airway. However, this technique comes with potential side effects, and more research is required to determine the benefits for critically ill intubated and mechanically ventilated patients.

The objectives of this workshop include:

• Demonstrating the important factors for safety and efficacy while following proper technique in a controlled fashion
• Providing the opportunity to practice with flows, volumes, and pressures in simulation
• Educating participants about clinical indications and contraindications

The hands-on experience is one of the things that makes EfCCNa so valuable to critical care nurses.

Standardized Critical Care Resuscitation and Emergency Airway Management

Nurses are participating in hospital CPR response teams more often than ever due to shortages of physicians. As a result, nurses require experience in emergency airway management to avoid ventilation-related complications.

The objectives of this workshop include:

• Presenting the practical application of the Difficult Airway Society, 2015 Guidelines and the National Tracheostomy Safety Project (NTSP) Guidelines for the management of a blocked tracheostomy tube
• Demonstrating difficult clinical emergency simulations with active participation
• Exploring the non-technical skills necessary for emergency airway management

After this workshop, nurses can feel confident when joining a CPR response team because they will be well aware of the potential risks and how to mitigate them.

Using Better Tools in the ICU

In addition to improving techniques, another growing trend is the use of better tools in the ICU. New innovative equipment improves safety for patients and practitioners, as well as improving the quality of care patients receive.

As the leading stopcock provider in the US and Europe, Elcam Medical continues to strive for better critical care by creating better tools such as the Marvelous Stopcock. Research shows that the Marvelous Stopcock improves patient and worker safety with its unique design.

Learn more about Marvelous Stopcock and how it helps critical care nurses.

We will be happy to meet you at out booth # S2. Contact us to schedule a meeting.

Source:

• http://www.efccna.org/congress
• http://www.efccna.org/programme/full-programme
• https://corner.acu.edu.au/research_supervision/framework/browse.php?srperid=3740
• http://www.efccna.org/images/2017_workshops.pdf
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3580733/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC29051/