The role of nurses in preventing adverse events related to respiratory dysfunction: literature review

Aims. This paper reports a literature review examining the relationship between specific clinical indicators of respiratory dysfunction and adverse events, and exploring the role of nurses in preventing adverse events related to respiratory dysfunction.

Background. Adverse events in hospital are associated with poor patient outcomes such as increased mortality and permanent disability. Many of these adverse events are preventable and are preceded by a period during which the patient exhibits clearly abnormal physiological signs. The role of nurses in preserving physiological safety by early recognition and correction of physiological abnormality is a key factor in preventing adverse events.

Methods. A search of the Medline and CINAHL databases was conducted using the following terms: predictors of poor outcome, adverse events, mortality, cardiac arrest, emergency, oxygen, supplemental oxygen, oxygen therapy, oxygen saturation, oxygen delivery, assessment, patient assessment, physical assessment, dyspnoea, hypoxia, hypoxaemia, respiratory assessment, respiratory dysfunction, shortness of breath and pulse oximetry. The papers reviewed were research papers that demonstrated a relationship between adverse events and various clinical indicators of respiratory dysfunction.

Results. Respiratory dysfunction is a known clinical antecedent of adverse events such as cardiac arrest, need for medical emergency team activation and unplanned intensive care unit admission. The presence of respiratory dysfunction prior to an adverse event is associated with increased mortality. The specific clinical indicators involved are alterations in respiratory rate, and the presence of dyspnoea, hypoxaemia and acidosis.

Conclusions. The way in which nurses assess, document and use clinical indicators of respiratory dysfunction is influential in identifying patients at risk of an adverse event and preventing adverse events related to respiratory dysfunction. If such adverse events are to be prevented, nurses must not only be able to recognise and interpret signs of respiratory dysfunction, but must also take responsibility for initiating and evaluating interventions aimed at correcting respiratory dysfunction.

Improving on- and off-campus student performance in structural mechanics

This paper investigates the performance of 329 (173 on- and 186  off-campus) students enrolled in two structural mechanics units at Deakin University, a leader in engineering distance-education in Australia. The two units experience unacceptably high rates of failure. An analysis of the assignment, laboratory and examination marks is presented. Consideration is also given to the total marks. The results show that on-campus students perform better in structural mechanics than their off-campus counterparts. Plots of the student performance distributions for the three assessment methods are provided (for each unit) and high failure rates are linked to low examination marks. Students tend to perform best in assignments and worst in examinations. Parametric statistical tests show a correlation between the continuous assessment and examination marks. To motivate students to fully participate in continuous assessment tasks the authors therefore propose several changes to the assessment criteria and marking schemes.

Delivery and assessment strategies to improve on- and off-campus student performance in structural mechanics

This paper considers the delivery and assessment strategies used in two structural mechanics units at Deakin University, a leader in distance education in Australia. The two units have had unacceptably high rates of student failure. Student perceptions of the delivery method were analysed and an investigation was carried out of the performance of 329 (173 on- and 156 off-campus) students enrolled in the two units. An analysis of the assignment, laboratory and examination marks is presented. Consideration is also given to the total marks. The results show that on-campus students performed better in structural mechanics than their off-campus counterparts. Plots of the distributions of student performance for the three assessment methods are provided (for each unit) and high failure rates are linked to low examination marks. Students tended to perform best in assignments and worst in examinations. Parametric statistical tests show a correlation between the marks obtained in continuous assessment and in examinations, and it is therefore proposed that, in order to improve performance, the students must be encouraged to participate fully in all aspects of the course. Many students were unenthusiastic about laboratory practical sessions and did not think they aided their understanding of the theoretical material. Motivation to participate is often dependent on the perceived relevance of a given task and its contribution to the total mark and, thus, to help motivate students to participate fully in the continuous assessment tasks, the authors propose several changes to the delivery methods, as well as to assessment criteria and marking schemes.

The cost of seasonal respiratory illnesses in Australian children: the dominance of patient and family costs and implications for vaccine use

Respiratory viral infections are one of the next group of diseases likely to be targeted for prevention in childhood by the use of vaccines. To begin collecting necessary epidemiology and cost information about the illnesses caused by these viruses, we conducted a prospective cohort study in 118 Melbourne children between 12 and 71 months of age during winter and spring 2001. We were interested in calculating an average cost per episode of community-managed acute respiratory disease, in identifying the key cost drivers of such illness, and to identify the proportion of costs borne by the patient and family. There were 202 community-managed influenza-like illnesses identified between July and December 2001, generating 89 general practitioner visits, and 42 antibiotic prescriptions. The average cost of community-managed episodes (without hospitalisation) was $241 (95% CI $191 to $291), with the key cost drivers being carer time away from usual activities caring for the ill child (70% of costs), use of non-prescription medications (5.4%), and general practice visits (5.0%). The patient and family met 87per cent of total costs. The lowest average cost occurred in households from the highest income bracket. Acute respiratory illness managed in the community is common, with the responsibility for meeting the cost of episodes predominantly borne by the patient and family in the form of lost productivity. These findings have implications for preventive strategies in children, such as the individual use of, or implementation of public programs using, currently available vaccines against influenza and vaccines under development against other viral respiratory pathogens.

The cost of community-managed viral respiratory illnesses in a cohort of healthy preschool-aged children

Background : Acute respiratory illnesses (ARIs) during childhood are often caused by respiratory viruses, result in significant morbidity, and have associated costs for families and society. Despite their ubiquity, there is a lack of interdisciplinary epidemiologic and economic research that has collected primary impact data, particularly associated with indirect costs, from families during ARIs in children.
Methods : We conducted a 12-month cohort study in 234 preschool children with impact diary recording and PCR testing of nose-throat swabs for viruses during an ARI. We used applied values to estimate a virus-specific mean cost of ARIs.
Results : Impact diaries were available for 72% (523/725) of community-managed illnesses between January 2003 and January 2004. The mean cost of ARIs was AU$309 (95% confidence interval $263 to $354). Influenza illnesses had a mean cost of $904, compared with RSV, $304, the next most expensive single-virus illness, although confidence intervals overlapped. Mean carer time away from usual activity per day was two hours for influenza ARIs and between 30 and 45 minutes for all other ARI categories.
Conclusion : From a societal perspective, community-managed ARIs are a significant cost burden on families and society. The point estimate of the mean cost of community-managed influenza illnesses in healthy preschool aged children is three times greater than those illnesses caused by RSV and other respiratory viruses. Indirect costs, particularly carer time away from usual activity, are the key cost drivers for ARIs in children. The use of parent-collected specimens may enhance ARI surveillance and reduce any potential Hawthorne effect caused by compliance with study procedures. These findings reinforce the need for further integrated epidemiologic and economic research of ARIs in children to allow for comprehensive cost-effectiveness assessments of preventive and therapeutic options.

The SARS (Severe Acute Respiratory Syndrome) pandemic in Hong Kong : effects on the subjective wellbeing of elderly and younger people

Objectives: This study examined the impact of the Severe Acute Respiratory Syndrome (SARS) outbreak in Hong Kong in 2003, on the subjective wellbeing (SWB) of elderly people and a younger comparative sample. The Personal Wellbeing Index (PWI), a contemporary instrument employed to measure SWB, was also examined for its psychometric performance to substantiate its use.

Method: A total of 302 older adults (age 65 + years) and 158 younger adults (age 35-46 years) were recruited from different districts. Data were collected by individual face-to-face interviews.

Result: While elderly people living in severely infected districts showed significantly lower levels of SWB, these levels and those of the younger sample were found to remain within the normative range. A major mitigating factor was an increased sense of community-connectedness. Other characteristics linked to low wellbeing levels included chronic illness, female gender, low education and unemployment. The living districts, characterized by varying extents of infection, had stronger associations with SWB than participants' age. The PWI demonstrated good psychometric performance and also more robustness with elderly people, including its sensitivity to the sense of population threat.

Conclusion: Psychological resilience was identified among both the elderly and younger age-groups in Hong Kong during the SARS pandemic. The PWI is verified as a suitable instrument for SWB measurements.

Where did we go wrong? An examination of students treatment of experimental error in engineering mechanics laboratories

The ability of engineers and applied scientists to undertake experimental measurements is a fundamental requirement of the profession. However, it is not simply good enough to be able to perform experiments if we are not able to interpret the results. In this study, reports prepared by mechanical engineering students were examined to determine how students dealt with the disparity between experimental measurements and theoretical results in their Engineering Mechanics laboratories. Analysis of the reports, and discussions with students in their laboratory classes, revealed a superficial understanding or regard for experimental error. This superficial treatment of experimental error is, most likely, due to a number of factors that are discussed. Some possible strategies for addressing the issue are also examined.

Respiratory muscle dysfunction and training in chronic heart failure

A characteristic feature of chronic heart failure (CHF) is reduced exercise tolerance. Several factors contributing to this have been identified, including alterations in central haemodynamics, skeletal muscle oxygen utilisation and respiratory muscle dysfunction. This review focuses on abnormalities identified in respiratory muscle structure and function in CHF and recent evidence for the benefit of selective inspiratory muscle training in CHF. Included in this review are findings from original investigations, with a specific focus on recent published data.

Respiratory pattern in awake rats : effects of motor activity and of alerting stimuli

Our aim was to assess the impact of motor activity and of arousing stimuli on respiratory rate in the awake rats. The study was performed in male adult Sprague–Dawley (SD, n = 5) and Hooded Wistar (HW, n = 5) rats instrumented for ECG telemetry. Respiratory rate was recorded using whole-body plethysmograph, with a piezoelectric sensor attached for the simultaneous assessment of motor activity. All motor activity was found to be associated with an immediate increase in respiratory rate that remained elevated for the whole duration of movement; this was reflected by: i) bimodal distribution of respiratory intervals (modes for slow peak: 336 ± 19 and 532 ± 80 ms for HW and SD, p < 0.05; modes for fast peak 128 ± 6 and 132 ± 7 ms for HW and SD, NS); and ii) a tight correlation between total movement time and total time of tachypnoea, with an R2 ranging 0.96–0.99 (n = 10, p < 0001). The extent of motor-related tachypnoea was significantly correlated with the intensity of associated movement. Mild alerting stimuli produced stereotyped tachypnoeic responses, without affecting heart rate: tapping the chamber raised respiratory rate from 117 ± 7 to 430 ± 15 cpm; sudden side move — from 134 ± 13 to 487 ± 16 cpm, and turning on lights — from 136 ± 12 to 507 ± 14 cpm (n = 10; p < 0.01 for all; no inter-strain differences). We conclude that: i) sniffing is an integral part of the generalized arousal response and does not depend on the modality of sensory stimuli; ii) tachypnoea is a sensitive index of arousal; and iii) respiratory rate is tightly correlated with motor activity.

Transcriptional insights on the regenerative mechanics of axotomized neurons in vitro

Axotomized neurons have the innate ability to undergo regenerative sprouting but this is often impeded by the inhibitory central nervous system environment. To gain mechanistic insights into the key molecular determinates that specifically underlie neuronal regeneration at a transcriptomic level, we have undertaken a DNA microarray study on mature cortical neuronal clusters maintained in vitro at 8, 15, 24 and 48 hrs following complete axonal severance. A total of 305 genes, each with a minimum fold change of ±1.5 for at least one out of the four time points and which achieved statistical significance (one-way ANOVA, P < 0.05), were identified by DAVID and classified into 14 different functional clusters according to Gene Ontology. From our data, we conclude that post-injury regenerative sprouting is an intricate process that requires two distinct pathways. Firstly, it involves restructuring of the neurite cytoskeleton, determined by compound actin and microtubule dynamics, protein trafficking and concomitant modulation of both guidance cues and neurotrophic factors. Secondly, it elicits a cell survival response whereby genes are regulated to protect against oxidative stress, inflammation and cellular ion imbalance. Our data reveal that neurons have the capability to fight insults by elevating biological antioxidants, regulating secondary messengers, suppressing apoptotic genes, controlling ion-associated processes and by expressing cell cycle proteins that, in the context of neuronal injury, could potentially have functions outside their normal role in cell division. Overall, vigilant control of cell survival responses against pernicious secondary processes is vital to avoid cell death and ensure successful neurite regeneration.

The mechanics of computation and human thought

Thousands of students are preparing for chemistry examinations in June. An unresolved debate is whether they should be permitted to use graphics and programmable calculators in those examinations. Some educators have not only advocated the use of graphics calculators, but have also pointed to the Danish system in which students are permitted to use computers in senior school examinations.

In some Australian jurisdictions, graphics calculators are permitted in year 12 mathematics examinations, but not in chemistry examinations. The reasoning is that information or methods of solving numerical chemical problems can be stored in the memory of graphics calculators, giving some students an unfair advantage. This means that chemistry students either have to learn how to use (and buy!) two types of calculators or, if they only have one calculator, are disadvantaged in using non-programmable calculators in mathematics examinations.

The use of technology (or its lack thereof) can limit how and what students learn. “The mechanics of computation and human thought” is an allusion to Asimov’s short story, “A Feeling of Power” in which, overuse of technology has caused people to forget how to do simple arithmetic. In our current assessment system, the insistence that students must be able to do simple chemical calculations has lead to underuse of available technology. The misperception is that the ability to do calculations is linked to understanding of concepts.

Graphics calculators, programmable calculators and computers are tools. Instead of banning or limiting technology, we should take the opportunity to rethink what is being assessed and how it is assessed. It is the proper use of technology, by combining the mechanics of computation and human thought to deepen understanding and to ask probing questions that truly leads to a feeling of power.

Functional imaging to understand biomechanics : a critical tool for the study of biology, pathology and the development of pharmacological solutions

We present four case studies of the literature discussing the effects of physical forces on biological function. While the field of biomechanics has existed for many decades, it may be considered by some a poor cousin to biochemistry and other traditional fields of medical research. In these case studies, including cardiovascular and respiratory systems, we demonstrate that, in fact, many systems historically believed to be controlled by biochemistry are dominated by biomechanics. We discuss both the previous paradigms that have advanced research in these fields and the changing paradigms that will define the progressions of these fields for decades to come. In the case of biomechanical effects of flowing blood on the endothelium, this has been well understood for decades. In the cases of platelet activation and liquid clearance from the lungs during birth, these discoveries are far more recent and perhaps not as universally accepted. While only a few specific examples are examined here, it is clear that not enough attention is paid to the possible mechanical links to biological function. The continued development of these research areas, with the inclusion of physical effects, will hopefully provide new insight into disease development, progression, diagnosis and effective therapies.