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Clinical Rounds

doi: 10.1097/01.NURSE.0000393750.51674.67
Department: CLINICAL ROUNDS
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SUICIDE PREVENTION

Keeping watch in EDs and med-surg units

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A new Joint Commission Sentinel Event Alert warns about the frequency of suicide by nonpsychiatric patients in EDs and medical-surgical units. Almost 25% of suicides reported to The Joint Commission (TJC) occurred in nonpsychiatric settings.

Some risk factors for these patients include dementia, traumatic brain injury, chronic pain or intense acute pain, poor prognosis or terminal diagnosis, and substance abuse. TJC recommends:

  • educating staff about suicide risk factors and warning signs that a suicide attempt is imminent.
  • empowering staff to call a mental health professional if they notice changes in a patient's behavior.
  • empowering staff to take action, such as placing a patient under constant observation if the patient exhibits suicide warning signs.

For more information and recommendations, visit TJC's website at http://www.jointcommission.org.

Source: The Joint Commission. A follow-up report on preventing suicide: focus on medical/surgical units and the emergency department. Sentinal Event Alert, November 17, 2010.

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PATIENT SAFETY

Discouraging news about error prevention

In a 6-year study at 10 North Carolina hospitals, researchers found scant evidence of widespread improvement in error prevention—despite intensive efforts to improve patient safety triggered by the Institute of Medicine's landmark report, To Err is Human.

In more than 2,300 randomly selected admissions, researchers found 588 instances of patient harm, including hospital-acquired infections, surgical errors, and drug dosage mistakes. Most errors were minor, but 50 were life-threatening. Fourteen patients died and 17 suffered permanent injury. About half of the errors were avoidable.

Although researchers identified a reduction in preventable harms, the reduction wasn't statistically significant. There was no significant change in the overall rate of harms, which includes both errors and unavoidable mistakes. Researchers call for more efforts to "translate effective safety interventions into routine practice and to monitor health care safety over time."

Source: Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363(22):2124–2134.

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TRAUMA UNITS

Tracking a shortage of surgeons

The state of emergency care may itself become an emergency. In a recent poll, three-quarters of ED directors said they lack on-call trauma surgeon coverage. One-quarter said their facility's trauma center designation had been downgraded or lost because of the shortage. Here are some other findings from the survey:

  • 60% of respondents said that in the last 4 years, their ED lost the ability to offer 24-hour coverage for at least one medical specialty.
  • More than 75% said their EDs have insufficient coverage for plastic surgery, hand surgery, and neurosurgery.
  • Almost 25% reported an increase in the number of patients who leave before seeing a specialist.
  • Inadequate trauma surgeon coverage was reported by 68% of teaching hospitals and 78% of nonteaching hospitals.

Source: Rao MB, Lerro C, Gross CP. The shortage of on-call surgical specialist coverage: a national survey of emergency department directors. Acad Emerg Med. 2010; 17(12):1374–1382.

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SPORTS INJURY PREVENTION

Tips for staying safe on the slopes

On average, 43 serious injuries from skiing or snowboarding are reported each year, according to the National Ski Area Association. The overall rate of ski injuries has declined by 50% since the 1970s, in part because of improved equipment and growing use of helmets by skiers and snowboarders. Last season, 57% wore helmets on the slopes, a 19% increase in helmet use compared with the 2002/2003 season. Among children, the figure rose to 87%.

But, although skiing and snowboarding are relatively safe, experts warn that high-risk behavior is the leading factor in fatal injuries. Ski areas routinely promote basic safety guidelines urging people to ski or snowboard within their ability, watch for skiers downhill, look uphill before entering a trail, and move to the side of the trail when stopping. For more information on staying safe on the slopes, visit http://www.nsaa.org/nsaa/press/facts-ski-snbd-safety.asp.

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THERAPEUTIC HYPOTHERMIA

Terminating life support too quickly?

In patients undergoing therapeutic hypothermia following cardiac arrest, decisions about withdrawing life support are typically based on a neurologic exam conducted about 72 hours after rewarming. But patients who received therapeutic hypothermia following cardiac arrest may not achieve full neurologic awakening for a week, say researchers reporting at a meeting of the American Heart Association.

Researchers evaluated 47 patients who survived nontraumatic out-of-hospital cardiac arrest. Fifteen patients received therapeutic hypothermia and 7 (47%) survived to discharge. Of the 32 patients who received conventional care without hypothermia, 13 (41%) survived to discharge.

Brain activity level was assessed daily in all patients, with these findings.

  • Within 3 days, about 38% of patients receiving conventional care were alert after resuscitation and had mild deficits. No hypothermia patients were alert and conscious at 3 days.
  • At day 7, 33% of hypothermia patients had regained alertness and were considered to have mild deficits.
  • At discharge, 83% of hypothermia patients were alert and considered to have only mild deficits.

Calling for further study to validate their findings, the researchers say the data suggest that neurologic awakening may begin at day 3, but not be complete until day 7 or even longer.

Another study presented at the meeting reinforced this conclusion. Researchers found that withdrawing life support 72 hours after rewarming "may prematurely terminate life in at least 10% of all potentially neurologically intact survivors" of cardiac arrest who received hypothermia treatment. In a small study, six cardiac arrest patients who showed signs of awakening more than 72 hours after rewarming had good neurologic function in 30 days.

For more information, visit the American Heart Association's website at http://www.newsroom.heart.org and search the "mediaroom" for Resuscitation Science Symposium.

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SURVEY RESPONSES

Does documentation take too much time?

Nurses who recently visited our website answered this question:

What percentage of your work time is spent on documentation?

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Answer monthly survey questions and see results from past surveys by visiting http://www.nursingcenter.com/poll, or check out the Quick Poll at http://www.nursing2011.com.

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PREVENTING PREMATURE DEATH

Eat your vegetables

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High-serum levels of alpha-carotene are associated with a decreased risk of death from cancer, cardiovascular disease, and all other causes, new research suggests. Yellow, orange, and dark green vegetables contain high levels of alpha-carotene.

Researchers evaluated the relationship between serum concentrations of alpha-carotene and mortality risk among 15,318 American adults age 20 and older. They found that subjects whose serum alpha-carotene levels were between 2 and 3 mcg/dL had a 23% lower risk of death from all causes when compared with those with low-serum alpha-carotene levels (between 0 and 1 mcg/dL). The higher the alpha-carotene levels, the greater the reduction in mortality risk: 27% for levels between 4 and 5 mcg/dL, 34% for levels between 6 and 8 mcg/dL, and 39% for levels of 9 mcg/dL or more.

Researchers say the findings "support increasing fruit and vegetable consumption as a means of preventing premature death."

Source: Li C, Ford ES, Zhao G, Balluz LS, Giles WH, Liu S.. Serum {alpha}-carotene concentrations and risk of death among US adults: The Third National Health and Nutrition Examination Survey Follow-up Study. Arch Intern Med. 2010 Nov 22. [Epub ahead of print]

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PROSTATE CANCER

Finger length forecasts risk

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Men whose index finger is longer than their ring finger have a 33% lower risk of developing prostate cancer than other men, according to new research that compared finger lengths in 1,500 prostate cancer patients with 3,000 healthy men.

Researchers believe the association may be related to in utero exposure to testosterone. Exposure to high levels of testosterone before birth increases the risk for prostate cancer later in life.

The most common finger length pattern is a shorter index than ring finger. Men whose index and ring fingers are the same length, which made up 19% of the study population, have a similar prostate cancer risk as men with short index fingers.

Source: Rahman AA, Lophatananon A, Brown SS, et al. Hand pattern indicates prostate cancer risk. Br J Cancer. 2010 Nov 30. [Epub ahead of print]

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In February, celebrate

© 2011 Lippincott Williams & Wilkins, Inc.