Mismanagement of delerium places patients at risk

Objective: This paper discusses the problem of delirium and the challenges of accurately assessing, preventing and managing patients with delirium in an acute care setting.

Primary Argument: Acute confusion, also known as delirium, is misdiagnosed and under-treated in up to 94% of older patients in hospitals. With the ageing population, this problem will increase dramatically in the Australian setting. Managing patients with delirium is challenging not only for the management of their basic nursing care needs but also because they are prone to adverse events such as falls and medication problems. In order to address this issue it is vital that health care professionals routinely assess patients for signs of delirium. The current 'gold standard' for assessing delirium is the use of the Confusion Assessment Method (CAM) which has been developed based on the diagnostic criteria set by the Diagnostic and Statistical Manual of Mental Disorders DSM-IV and can be used by non-psychiatrists. Further, increased attention should be given to the prevention and management of delirium and the use of orientation and validation therapy.

Conclusion: Research indicates that early identification and intervention can help to limit any negative effects or adverse events. Increasing knowledge and awareness of early detection and efficient management of delirium is the first step toward prevention.

Complementary therapies and diabetes

There is increasing recognition that people with diabetes use a range of complementary therapies (CT), for a number of conditions, but do not always inform their conventional health practitioners about their use. Controlling blood glucose levels in people with diabetes is important to reduce the consequent metabolic abnormalities and symptoms and the incidence of long-term complications. Conventional medical and nursing practitioners often incorrectly assume that they are used to control blood glucose levels, e.g. using herbal medicines to increase insulin production or reduce insulin resistance. CT can be beneficial for people with diabetes. They can also lead to adverse events. This paper describes the outcome of monitoring complementary therapy use in our diabetic outpatient services in 2001, the results of a focus group (n=10) to explore issues identified in the monitoring process and a survey undertaken with a convenience sample of diabetes educators (n=40).

Twenty percent of patients used CT and there were three adverse events in the monitoring phase. Eight of the 10 focus group participants used CT and 16 of the diabetes educators used CT in patient care. Only one had a complementary therapy qualification.

Medication knowledge and self-management by people with type 2 diabetes

Objective: To explore medication knowledge and self management practices of people with type 2 diabetes.

Design: A one-shot cross sectional study using in-depth interviews and participant observation.

Setting: Diabetes outpatient education centre of a university teaching hospital.

Subjects: People with type 2 diabetes, n=30, 17 males and 13 females, age range 33-84, from a range of ethnic groups.

Outcome measures: Ability to state name, main actions and when to take medicines. Performance of specific medication-related tasks; opening bottles and packs, breaking tablets in half, administering insulin, and testing blood glucose.

Results: Average medication use > or = 10 years. Respondents were taking 86 different medicines, mean 7 +/- 2.97 SD. Dose frequency included two, three and four times per day. All respondents had > or = 2 diabetic complications +/- other comorbidities. The majority (93%) were informed about how and when to take their medicines, but only 37% were given information about side effects and 17% were given all possible seven items of information. Younger respondents received more information than older respondents. Older respondents had difficulty opening bottles and breaking tablets in half. Twenty per cent regularly forgot to take their medicines. Increasing medication costs was one reason for stopping medicines or reducing the dose or dose interval. The majority tested their blood glucose but did not control test their meters and 33% placed used sharps directly into the rubbish.

Conclusion: Polypharmacy was common. Medication knowledge and self management were inadequate and could lead to adverse events.

A randomized comparison of quadruple and triple therapies for helicobacter pylori eradication: The QUADRATE study.

Background & Aims: Direct comparisons of bismuth and proton pump inhibitor (PPI)-based triple and quadruple therapies for Helicobacter pylori eradication are lacking. To address this, a randomized study was conducted.Methods: Infected dyspeptic patients received pantoprazole 40 mg, amoxicillin 1000 mg, and clarithromycin 500 mg, all twice daily, for 7 days (PAC7); or pantoprazole 40 mg twice daily, bismuth subcitrate 108 mg, and tetracycline 500 mg, both 4 times daily, and metronidazole 200 mg 3 times daily and 400 mg at night for 7 days (PBTM7); bismuth subcitrate 108 mg and tetracycline 500 mg, both 4 times daily, and metronidazole 200 mg 3 times daily and 400 mg at night for 14 days (BTM14). Outcome was assessed with ¹³C-urea breath test.Results: Eradication rates (intention to treat [n = 405]/per protocol [n = 320]) were similar for PAC7 (78%/82%) and PBTM7 (82%/88%); the latter significantly superior to BTM14 (69%/74%; P < 0.01). Pretreatment metronidazole resistance (MR) was 53% and clarithromycin resistance was 8%. Eradication rates for primary metronidazole sensitive/resistant isolates were 74%/87% with PAC7 and 80%/81% for PBTM7, compared with 76%/55% (P < 0.02) for BTM14. Noncompliance was greater with BTM14 (15%; P < 0.001) than PAC7 (3%) or PBTM7 (6%). Moderate-severe adverse events were more common with BTM14 (45%; P < 0.001), than PAC7 (23%) or PBTM7 (25%) with more discontinuations (9%, 2%, 3%, respectively).Conclusions: One-week PPI triple therapy is well tolerated and effective. The addition of PPI to bismuth triple therapy allows reduction of treatment duration with improved efficacy and tolerability, despite a high rate of MR. Quadruple therapy appears to overcome pretreatment MR in most cases. Two-week bismuth triple therapy is significantly inferior to quadruple therapy and less well tolerated than both 1-week therapies.

A randomized controlled trial of buprenorphine in the management of short-term ambulatory heroin withdrawal

Aim: To determine whether buprenorphine is more effective than clondine and other symptomatic medications in managing ambulatory heroin withdrawal.
Design: Open label. prospective randomized controlled trial examining
withdrawal and 4-week postwithdrawal outcomes on intention-to-treat.
Setting: Two specialist, out-patient drug treatment centres in inner city
Melbourne and Sydney, Australia.
Participants: One hundred and fourteen dependent heroin users were recruited. Participants were 18 yea rs or over. and with no significant other drug dependence, medical or psychiatric conditions or recent methadone treatment. One hundred and one (89%) participants completed a day 8 research interview examining withdrawal outcomes, and 92 (81%) completed day 35 research interview examining postwithdrawal outcomes.
Interventions: Participants randomized to control (n = 56) (up to 8 days or
clonidine and other symptomatic medications) or experimental (n = 58) (up to 5 days of buprenorphine) withdrawal groups. Following the 8-day withdrawal episode, participants could self-select from range of postwithdrawal options (naltrexone, substitution maintenance or counselling).
Measurements: Retention in withdrawal: heroin use during withdrawl: and
retention in drug treatment 4 weeks after withdrawal.
Secondary outcomes: Withdrawal severity: adverse events, and heroin use in the postwithdrawal period.
Findings: The experimental group had better treatment retention at day 8 (86% versus 57%, P = 0.001, 95% CI for numbers needed to treat (NNT) = 3-8) and day 35 (62% versus 39%, P = 0.02, 95% CI for NNT = 4-18): used heroin on fewer days during the withdralwal programlme (2.6 ± 2.5 versus 4.5 ± 2. 3.
P < 0.001. 95% CI = 1- 2.5 days) and in the postwithdrawal period (9.0±8.2
versus 14.6± 10. P<O.Ol. 95% CI = I .8- 9.4): and reported less withdrawal
severity. No severe adverse events reported.
Conclusions: Buprenorphine is effective for short-term ambulatory heroin
withdrawaI, with greater retention, less heroin use and less withdrawal discomfort during withdrawal: and increased postwithdrawal treatment retention than symptomatic medications.

Acetylcysteine for prevention of acute deterioration of renal function following elective coronary angiography and intervention

Context The antioxidant acetylcysteine prevents acute contrast nephrotoxicity in patients with impaired renal function who undergo computed tomography scanning. However, its role in coronary angiography is unclear.

Objective To determine whether oral acetylcysteine prevents acute deterioration in renal function in patients with moderate renal insufficiency who undergo elective coronary angiography.

Design and Setting Prospective, randomized, double-blind, placebo-controlled trial conducted from May 2000 to December 2001 at the Grantham Hospital at the University of Hong Kong.

Participants Two hundred Chinese patients aged mean (SD) 68 (6.5) years with stable moderate renal insufficiency (creatinine clearance <60 mL/min [1.00 mL/s]) who were undergoing elective coronary angiography with or without intervention.

Intervention Participants were randomly assigned to receive oral acetylcysteine(600 mg twice per day; n = 102) or matching placebo tablets (n = 98) on the day before and the day of angiography. All patients received low-osmolality contrast agent.

Main Outcome Measures Occurrence of more than a 25% increase in serum creatinine level within 48 hours after contrast administration; change in creatinine clearance and serum creatinine level.

Results Twelve control patients (12%) and 4 acetylcysteine patients (4%) developed a more than 25% increase in serum creatinine level within 48 hours after contrast administration (relative risk, 0.32; 95% confidence interval [CI], 0.10-0.96; P = .03). Serum creatinine was lower in the acetylcysteine group (1.22 mg/dL [107.8 µmol/L]; 95% CI, 1.11-1.33 mg/dL vs 1.38 mg/dL [122.9 µmol/L]; 95% CI, 1.27-1.49 mg/dL; P = .006) during the first 48 hours after angiography. Acetylcysteine treatment significantly increased creatinine clearance from 44.8 mL/min (0.75 mL/s) (95% CI, 42.7-47.6 mL/min) to 58.9 mL/min (0.98 mL/s) (95% CI, 55.6-62.3 mL/min) 2 days after the contrast administration (P<.001).The increase was not significant in the control group (from 42.1 to 44.1 mL/min [0.70 to 0.74 mL/s]; P = .15). The benefit of acetylcysteine was consistent among various patient subgroups and persistent for at least 7 days. There were no major treatment-related adverse events.

Conclusion Acetylcysteine protects patients with moderate chronic renal insufficiency from contrast-induced deterioration in renal function after coronary angiographic procedures, with minimal adverse effects and at a low cost.

Clinical risk managment and the ethics of open disclosure : part 2 : implications for the nursing profession

Patient safety experts and other authorities have strongly postulated the open disclosure of errors and adverse events to patients and their nominated support persons as an essential component of effective clinical risk management in health care. Commentators also contend that ‘when things go wrong’, openly disclosing such events to the patient is simply ‘the right thing to do’. Important questions about the ethics of open disclosure remain, however. Is openly disclosing errors and adverse events to patients necessarily ‘the right thing to do’? Do hospital authorities and health care professionals always have an overriding duty to openly communicate with patients and their families when thing go wrong? If patients do not suffer any material harm when a mistake is made, should they or their nominated support persons still be told? Are there overriding moral considerations that might justify non-disclosure in certain circumstances? Despite the obvious importance of these issues and their possible implications for the nursing profession, they have not been comprehensively explored in the nursing literature. An important aim of this article (the second of a two-part discussion) is to contribute to the positive project of redressing this oversight.

Clinical risk management and the ethics of open disclosure : part 1 : benefits and risks to patient safety

Patient safety experts and other authorities have strongly postulated the open disclosure of errors and adverse events to patients as an essential component of effective clinical risk management in health care. Commentators also contend that ‘when things go wrong’, openly disclosing such events to the patient and his or her nominated support person is simply ‘the right thing to do’. Despite the obvious importance of the issue of open disclosure and its possible implications for the nursing profession, it has not been comprehensively addressed in the nursing literature. A key aim of this article (the first of a two-part discussion) is to contribute to the positive project of redressing this oversight by providing a brief overview of what open disclosure is and what its intended purpose, aims, and rationale are. Consideration is also given to the risks and benefits of open disclosure as a public policy and whether it will succeed in achieving the anticipated outcomes envisaged. In a second article (to be presented as Part II), the ethics of open disclosure and its possible implications for the nursing profession are explored.

Engaging patients as safety partners : some considerations for ensuring a culturally and linguistically appropriate approach

Engaging patients as ‘safety partners’ with health service providers to help identify and rectify preventable adverse events in health care is being increasingly accepted in the USA, Australia, and elsewhere as a promising strategy to improve patient safety outcomes. The implications of this trend for patients and families of minority cultural and language backgrounds have not, however, been comprehensively considered. In this article, attention is given to briefly exploring the notion of patient participation in health care and the problematic transposition of the concept into patient safety discourse. The importance of recognising and responding to the critical relationship between culture, language and
patient safety outcomes, and the possible benefits and risks of engaging patients of minority ethnic backgrounds in safety partnership programs are explored. It is suggested that if patient safety engagement/partnership programs are to perform well in cross-cultural health care contexts, they need to be supported by research evidence and appropriately informed by the perspectives and experiences of patients and families/nominated carers from minority cultural and language backgrounds. They also need to be appropriately supported by culturally competent policies and practices across the entire health care system. The importance of robust internationally comparative research on this issue is highlighted.

Lateral positioning for critically ill adult patients

We aim to assess the effect of the lateral position compared to other body positions on patient outcomes (mortality, morbidity and clinical adverse events during and following positioning) in critically ill adult patients. We will examine the single use of the lateral position (that is on the right or left side) and repeat use of the lateral position(s) in a positioning schedule (that is lateral positioning). We plan to undertake subgroup analysis for primary disease and condition, severity of illness, the presence of assisted ventilation and angle of lateral rotation.

Tracheostomy decannulation failure rate following critical illness : a prospective descriptive study

Background : Tracheostomy is a well established and practical approach to airway management for patients requiring extended periods of mechanical ventilation or airway protection. Little evidence is available to guide the process of weaning and optimal timing of tracheostomy tube removal. Thus, decannulation decisions are based on clinical judgement. The aim of this study was to describe decannulation practice and failure rates in patients with tracheostomy following critical illness.

Methods : A prospective descriptive study was conducted of consecutive patients who received a tracheostomy at a tertiary metropolitan public hospital intensive care unit (ICU) between March 2002 and December 2006. Data were analysed using descriptive and inferential tests.

Results : Of the 823 decannulation decisions, there were 40 episodes of failed decannulation, a failure rate of 4.8%. These 40 episodes occurred in 35 patients: 31 patients failed once, 3 patients failed twice and 1 patient failed three times. There was no associated mortality. Simple stoma recannulation was required in 25 episodes, with none of these patients readmitted to ICU. Translaryngeal intubation and readmission to ICU took place for the remaining 15 episodes. The primary reason for decannulation failure was sputum retention. Twenty-four patients (60%) failed decannulation within 24 h, with 14 of these occurring within 4 h.

Conclusions : Clinical assessments coupled with professional judgement to decide the optimal time to remove tracheostomy tubes in patients following critical illness resulted in a failure rate comparable with published data. Although reintubation and readmission to ICU was required in just over one third of failed decannulation episodes, there was no associated mortality or other significant adverse events. Our data suggest nurses need to exercise high levels of clinical vigilance during the first 24 h following decannulation, particularly the first 4 h to detect early signs of respiratory compromise to avoid adverse outcomes.

Another look at the culture-quality-performance link

Quality improvement is usually driven by quality, safety and risk agendas leading to a focus on measurements of the outputs of care; outputs such as fewer complaints, fewer accidents and adverse events. An oft-neglected theme is the impact of the quality improvement initiative within the organisation itself. This paper presents the findings of the first stage of an evaluation that has examined the changes which have occurred within organisations since participating in a quality improvement initiative. These findings indicate that engaging with a quality improvement program can change the nature of social interactions within the organisation. In this way, quality improvement programs can impact on organisational culture, particularly in relation to organisational learning. Thus, this paper argues that successful engagement with a quality improvement program can enhance organisational learning, and, in turn, build organisational capacity.

Culture, language, and patient safety : making the link

It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care programmes to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks. Despite the progress that has been made in improving hospital safety in recent years, there is emerging evidence that patients of minority cultural and language backgrounds are disproportionately at risk of experiencing preventable adverse events while in hospital compared with mainstream patient groups. One reason for this is that patient safety programmes have tended to underestimate and understate the critical relationship that exists between culture, language, and the safety and quality of care of patients from minority racial, ethno-cultural, and language backgrounds. This article suggests that the failure to recognize the critical link between culture and language (of both the providers and recipients of health care) and patient safety stands as a ‘resident pathogen’ within the health care system that, if not addressed, unacceptably exposes patients from minority ethno-cultural and language backgrounds to preventable adverse events in hospital contexts. It is further suggested that in order to ensure that minority as well as majority patient interests in receiving safe and quality care are properly protected, the culture–language–patient-safety link needs to be formally recognized and the vulnerabilities of patients from minority cultural and language backgrounds explicitly identified and actively addressed in patient safety systems and processes.

The moral imperative of designating patient safety and quality care as a national nursing research priority

Since the early 1990s, research studies conducted respectively in the USA, UK and Australia have found that between 4 and 16.6 per cent of patients suffer from some kind of harm (including permanent disability and death) as a result of human errors and adverse events while in hospital. It has been further estimated that approximately 50 per cent of these human errors/adverse events resulting in harm could have been prevented. In response to the significant financial, social, and political implications of these figures, a range of processes have been put in place in an attempt to improve patient safety and quality care in Australia. Nonetheless, it is evident that more can be done to improve the status quo. One process that warrants consideration is that of peak health professional groups and organisations providing active leadership in the promotion of patient safety, such as by making a visible and recognisable commitment to patient safety as a strategic research priority area. In this paper it is contended that, given the moral importance of patient safety and quality care in nursing and related health care domains, the inseparable link between nursing practice and patient safety, and the central role that research has to play in driving safety improvements in these domains, it is morally imperative that the nursing profession gives sustained and focussed public attention to patient safety and quality care as a national research priority.