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Clinical Informationist at EUH Branch Library

What is the evidence on strategies for coping with moral distress for nurses working with heart failure patients?

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There are several relevant papers on coping strategies, but not specific to heart failure.

Search strategy (database and search terms):

Joanna Briggs
Search terms: moral distress

Identified a systematic review that includes some discussion of coping.
How professional nurses working in hospital environments experience moral distress: a systematic review.
Rittenmeyer L, Huffman, D.  How professional nurses working in hospital environments experience moral distress: a systematic review.  The JBI Library of Systematic Reviews. 7(28):1234-1291, 2009.

PubMed

This search identifies over a hundred articles.  You may be especially interested in these references that are available through this search:

Moral distress: levels, coping and preferred interventions in critical care and transitional care nurses.  Wilson MA, Goettemoeller DM, Bevan NA, McCord JM. J Clin Nurs. 2013 May;22(9-10):1455-66. doi: 10.1111/jocn.12128. Epub 2013 Mar 8.
PMID: 23473022

How professional nurses working in hospital environments experience moral distress: a systematic review.  Huffman DM, Rittenmeyer L. Crit Care Nurs Clin North Am. 2012 Mar;24(1):91-100. doi: 10.1016/j.ccell.2012.01.004. Epub 2012 Feb 3. Review.
PMID: 22405714

Innovative solutions: the effect of a workshop on reducing the experience of moral distress in an intensive care unit setting.  Beumer CM. Dimens Crit Care Nurs. 2008 Nov-Dec;27(6):263-7. doi: 10.1097/01.DCC.0000338871.77658.03.
PMID: 18953194

Defining and addressing moral distress: tools for critical care nursing leaders.  Rushton CH. AACN Adv Crit Care. 2006 Apr-Jun;17(2):161-8.
PMID: 16767017

Identified one article on managing heart failure that discusses moral distress.
Nurs Res. 2014 Sep-Oct;63(5):357-65. doi: 10.1097/NNR.0000000000000049.
Managing heart failure in the long-term care setting: nurses’ experiences in Ontario, Canada.  Strachan PH.

For inpatients and outpatients, how frequently is Vitamin D screening conducted and how frequently is it done on request versus routinely?

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Bottom line:  Apart from special populations with known risk for Vitamin D deficiency, there is no evidence regarding practices of Vitamin D screening in general inpatient or outpatient populations.

PubMed search:   vitamin d AND “mass screening”[mesh] AND routine*
This search includes 2 papers published in American Family Physician in 2013.  They present opposing viewpoints on routine screening.  It is probably worth looking at those papers, especially the reference lists.
No papers reported on provider practices regarding Vitamin D screening.

A broader PubMed search of vitamin D and “mass screening”[mesh] seems to address screening in special populations, such as pregnant women, the elderly, and individuals with diabetes.

Web of Science:  Similar results to the PubMed search were found. A recent review presents evidence on Vitamin D screening.

Kulie, Teresa, et al. “Vitamin D: an evidence-based review.” Journal of the American Board of Family Medicine 22.6 (2009):698-706. (cited 33 times)
The last sentence of abstract reads: Unfortunately, little evidence guides clinicians on when to screen for vitamin D deficiency or effective treatment options.

You might be able to use the National Ambulatory Medical Care Survey to determine an estimation of how many patient visits included vitamin D tests, but you wouldn’t be able to tell if they were routine.  There is also a National Hospital Care Survey that might provide similar data; again you wouldn’t be able to tell if they were ordered as a routine or in response to clinical findings or patient history.  If you are interested, we can investigate that further.

What is the evidence linking disposable ECG cables and lead wire systems to decreased hospital acquired infections (HAIs)? What would the cost savings be?

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Studies focus on identifying presence of bacteria on devices, as opposed to devices being associated as the cause of HAI cases.  Likewise, no published literature was identified that specifically demonstrated that use of disposable leads reduces the rate of HAIs.

Evidence Summary sources:

Joanna Briggs
Xue, Yifan. Noninvasive Portable Clinical Items: Healthcare Associated Infections. [Evidence Summaries]. JBI11266, 2014.
Cites studies demonstrating the prevalence of low-risk, potentially pathogenic, and multidrug resistant bacteria on non-invasive devices, including ECG lead wires.

Literature databases:

PubMed:  cross infection AND (electrocardiography OR noninvasive devices) AND (disposable OR reusable OR reuse OR “single use”)

Microbial colonization of electrocardiographic telemetry systems before and after cleaning.
Reshamwala A, McBroom K, Choi YI, LaTour L, Ramos-Embler A, Steele R, Lomugdang V, Newman M, Reid C, Zhao Y, Granger BB.
Am J Crit Care. 2013 Sep;22(5):382-9. doi: 10.4037/ajcc2013365.
PMID: 23996417
contamination after cleaning reusable leads

Disposable vs reusable electrocardiography leads in development of and cross-contamination by resistant bacteria.
Brown DQ.
Crit Care Nurse. 2011 Jun;31(3):62-8. doi: 10.4037/ccn2011874.
PMID: 21632593
Review article

Cleaned, ready-to-use, reusable electrocardiographic lead wires as a source of pathogenic microorganisms.
Albert NM, Hancock K, Murray T, Karafa M, Runner JC, Fowler SB, Nadeau CA, Rice KL, Krajewski S.
Am J Crit Care. 2010 Nov;19(6):e73-80. doi: 10.4037/ajcc2010304.
PMID: 21041188
presence of pathogens on reusable leads

Potential micro-organism transmission from the re-use of 3M Red Dot adhesive electrocardiograph electrodes.
Daley AJ, Hennessy D, Cullinan J, Thorpe S, Alexander R.
J Hosp Infect. 2005 Nov;61(3):264-5. Epub 2005 Jul 5. No abstract available.
PMID: 16002182

CINAHL

A similar search of CINAHL did not identify any unique, relevant articles.

Cost savings

The cost savings of decreasing HAIs can be calculated by multiplying the estimated cost of  an HAI by the number of HAIs in a given period of time.  Then, subtract the cost of disposable equipment for all procedures occurring during that time period (i.e., the number of disposable cables that would be used with patients).

The CDC provides data on estimated cost of HAIs.  Start at http://www.cdc.gov/hai/surveillance/. The Direct Medical costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention, 2009, includes estimates for specific types of infections beginning on p. 5.

What is the evidence for oral care of a patient on a ventilator?

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The systematic reviews identified below include slightly different findings, so a review of the objective of each review, as well as the patient populations in the included studies, will be important for extrapolating results to a specific setting.  Guidelines were identified in DynaMed and in PubMed.

Evidence summary resources

From Mechanical Ventilation entry.  In:  DynaMed Plus.
Under Adjunctive Therapies > Other Supportive Care

  • A systematic review (JAMA 2014) found that oral care with chlorhexidine may reduce lower respiratory tract infections in adults following cardiac surgery, but is not associated with reduction in VAP in non-cardiac surgery patients.  The review was limited by the heterogeneity of the settings/populations.

JAMA Intern Med. 2014 May;174(5):751-61. Klompas M, et al. Reappraisal of routine oral care with chlorhexidine gluconate for patients receiving mechanical ventilation: systematic review and meta-analysis.

  • A systematic review (with heterogeneity) of 6 RCTs concluded that toothbrushing may not reduce risk of ventilator-associated pneumonia in critically ill patients
  • Society for Healthcare Epidemiology of America (SHEA) guideline on strategies to prevent ventilator-associated pneumonia in acute care hospitals Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S31

From Joanna Briggs

Oral Hygiene Care: Acute Care Setting.  Chu WH.  [Evidence Summaries], AN: JBI5215, 2013.
References a systematic review (Cochrane 2013) concluded that use of chlorhexidine was associated with reduction in rate of VAP in adult, but not pediatric, patients.

Cochrane Database Syst Rev. 2013 Aug 13;8:CD008367.   Shi Z, et al. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia.

Oral Care.  [Recommended Practices, AN: JBI5264, 2013.
References a systematic review (Am J Crit Care 2007) concluding that toothbrushes can be a source of contamination and should be kept clean.

PubMed

View the results of a search for relevant systematic reviews and meta-analyses:
(“Pneumonia, Ventilator-Associated/prevention and control”[Mesh] OR “Respiration, Artificial/adverse effects”[Mesh]) AND (“Anti-Infective Agents, Local”[nm] OR “oral hygiene”[MeSH Terms]) AND (Meta-Analysis[ptyp] OR systematic[sb])

Additional guideline

Berry AM, et al. Consensus based clinical guideline for oral hygiene in the critically ill. Intensive Crit Care Nurs. 2011 Aug;27(4):180-5.

What is the evidence on family members being present during cardiopulmonary resuscitation?

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A search of DynaMed and Joanna Briggs did not identify RCTs or other documents that referenced  RCTs evaluating family presence during resuscitation.

A PubMed search of resuscitation AND family – Filtered by Randomized Controlled Trial only identified one RCT.  Removing the filter and adding “randomized OR random” as search terms did not identify additional studies.
Family presence during cardiopulmonary resuscitation.
Jabre P, et al. N Engl J Med. 2013 Mar 14;368(11):1008-18. doi: 10.1056/NEJMoa1203366.
PMID: 23484827

Family presence during resuscitation: a randomised controlled trial of the impact of family presence. Holzhauser K; Finucane J; De Vries SM; Australasian Emergency Nursing Journal, 2006; 8 (4): 139-47.

There are also quasi-experimental studies included in these search results.

What is the evidence of the effects of electrolyte imbalances and fluid resuscitation on outcomes for patients undergoing surgery? Of particular interest is the population of cardiac surgery patients.

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ELECTROLYTE IMBALANCES

A review of evidence in DynaMed identified the following:

Hyponatremia, Prognosis Section Large cohort study (N=950,000+ patients having major surgery).  Patients with preoperative hyponatremia had statistically significantly higher rates of 30-day all-cause mortality,perioperative major coronary events,wound infections, and pneumonia as compared to patients with normal sodium levels.  Arch Intern Med 2012 Oct 22;172(19):1474,

Hypokalemia, Complications Section.  A large prospective cohort study of patients undergoing elective coronary artery bypass grafting showed that patients with hypokalemia may have increased odds of having a perioperative arrhythmia and need for CPR.  JAMA 1999 Jun 16;281(23):2203

A PubMed search (“hypocalcemia”[mesh] OR “hypercalcemia”[mesh] OR “hyperkalemia”[mesh] OR “hypokalemia”[mesh] OR “hypophosphatemia”[mesh] OR “hyperphosphatemia”[mesh]) AND (“Surgical Procedures, Operative”[Mesh]) AND (case-control OR cohort study OR retrospective) identified several additional studies which are available in this MyNCBI Collection.

FLUID RESUSCITATION

Consult the book “Clinical Fluid Therapy in the Perioperative Setting”, 2011.  It is available in the EUH Library and cites evidence for fluid therapy in various settings.

In PubMed, this search will include reports of clinical trials that address fluid therapy in perioperative care of cardiac surgery patients:

(“Isotonic Solutions”[Mesh] OR “Fluid Therapy”[Mesh] OR “Ringer’s solution, potassium-free” [Supplementary Concept] OR “Ringer’s lactate” [Supplementary Concept] OR “bicarbonated Ringer’s solution” [Supplementary Concept] OR “Ringer’s solution” [Supplementary Concept] OR “crystalloid solutions” [Supplementary Concept] OR “Plasmalyte A” [Supplementary Concept] OR “Plasmalyte R” [Supplementary Concept] OR hetastarch) AND “Perioperative Care”[Mesh] AND ( “Thoracic Surgery”[Mesh] OR “Cardiac Surgical Procedures”[Mesh] ) Limits: Clinical Trials, Meta-analysis, Systematic Review

Are there methods that are effective at reducing nursing staff response time to patient call lights/bed alarms?

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A search of PubMed, CINAHL, and ECRI (a quality and risk management resource) for combinations of these terms:
Call lights, call buttons, intercoms, stimuli
Patients, beds, rooms
Nurses, nursing
Response time, reaction time, attention
(call lights OR call buttons OR alarms) AND (patients OR beds OR rooms) AND (nurses OR nursing) AND (response time OR reaction time)…identified many articles about reducing the rate of call light use by implementing hourly/intentional/comfort rounding, as well as the association between call light use and falls. Below are a couple of references that explore how psychological factors may be associated with response time.

Kalisch BJ, et al. Nursing teamwork and time to respond to call lights: an exploratory study. Rev Lat Am Enfermagem. 2013 Jan-Feb;21 Spec No:242-9.

Tzeng HM. Perspectives of staff nurses toward patient- and family-initiated call light usage and response time to call lights. Appl Nurs Res. 2011 Feb;24(1):59-63. doi: 10.1016/j.apnr.2009.03.003. Epub 2009 Jul 9.

A Google search for no pass zone patient call lights identified several hospitals that have rolled out campaigns with this name, but there doesn’t seem to be anything in the traditional published literature about them. Here is information from a couple of hospitals in case you want to contact them directly for additional information.

http://nursing.advanceweb.com/News/Regional-News/Bronx-NY-Montefiore-Establishes-No-Passing-Zone.aspx

http://healthleadersmedia.com/content/NRS-250810/Nurses-Find-Simple-Ways-to-Improve-Satisfaction##

http://1199seiubenefits.org/wp-content/uploads/2012/01/Mt.-Sinai-Powerpoint.pdf

This question seems to be similar to alert fatigue with use of alerts in clinical systems. After browsing some of those references in PubMed, I applied the subject headings
(“Human engineering”[mesh] OR “Hospital communication systems”[mesh]) AND (“Reaction time”[mesh] OR “time factors”[mesh]) AND nurses AND (falls OR patient satisfaction)
The most relevant reference in this search is below. It discusses use of a different technology.
Guarascio-Howard L. Examination of wireless technology to improve nurse communication, response time to bed alarms, and patient safety. HERD. 2011 Winter;4(2):109-20.