Nursing Research: Show me the evidence!

Intraoperative Radiation Therapy

2009-10-14T10:30:00.001-07:00

Intraoperative Radiation Therapy (IORT)

St. Joseph Hospital has pioneered a new technology that improves breast cancer outcomes, decreases the amount of post-operative radiation required, preserves healthy breast tissue and increases patient comfort.The hospital remains at the forefront of medical innovation with the introduction of Intraoperative Radiation Therapy (IORT), one of the most advanced forms of radiation therapy available in the United States.

IORT delivers highly targeted beams of radiation directly to a tumor site during surgery. In addition to improving patient outcomes, this direct application improves patient comfort by preserving healthy tissue surrounding the tumor and reducing the amount of radiation patients may need after surgery. For patients and their families, this means less stress and more time for healing.Intraoperative Radiation Therapy (IORT) delivers highly targeted beams of radiation during surgery. Studies show that radiating the tumor site in the breast immediately following tumor resection reduces the risk of the cancer returning.

As Orange County’s first hospital to offer this innovative treatment during breast surgery, Stacey Fischer, Breast Program Nurse Navigator, is also available to assist you and your patients should you have any questions concerning IORT or the Breast Program. She can be reached at (714) 734-6233.

Poster on our blog presented at the 2009 ANCC Magnet Conference

2009-10-09T07:56:00.000-07:00

Our blog, Nursing Research: Show me the Evidence! was presented as a poster at the 2009 ANCC Magnet Conference Oct 1-3 in Louisville, Kentucky. Dana Rutledge, RN, PhD presented the poster on behalf of Julie Smith, MLS, Library Manager. Be sure to check out our blog out at http://evidencebasednursing.blogspot.com/

Commentary on Survey of Public's Knowledge/Attitudes about Resuscitation

2009-10-07T15:40:00.000-07:00

Research Abstract with Commentary

Cardiopulmonary Resuscitation: Knowledge and Opinions Among the U.S. General Public.
State of the Science-Fiction

BACKGROUND AND OBJECTIVE: Cardiopulmonary resuscitation is undertaken more than 250,000 times annually in the United States. This study was undertaken to determine knowledge and opinions of the general public regarding cardiopulmonary resuscitation. DESIGN: Validated multisite community-based cross-sectional survey. OUTCOME MEASURES: Knowledge and opinions about resuscitative practices and outcomes, using hypothetical clinical scenarios and other social, spiritual, and environmental considerations. RESULTS: Among 1831 participants representing 38 states, markedly inaccurate perceptions of cardiac arrest were reported. Participants' mean estimate of predicted survival rate after cardiac arrest was 54% (median 50%, IQR 35-75%), and mean estimated duration of resuscitative efforts in the ED was 28min (median 15min; IQR 10-30). Projected age and health status were independent predictors of resuscitation preferences in a series of 4 hypothetical scenarios. Participants indicated that physicians should consider patient and family wishes as the most important factors when making resuscitation decisions. Participants considered advanced technology and physician communication to be the most important actions during attempted resuscitation. CONCLUSIONS: Inaccurate perceptions regarding resuscitation and survival rates exist among the lay public. Participants indicated strong preferences regarding resuscitation and advance directives.

Marco, C. A., & Larkin, G. L. (2008). Cardiopulmonary resuscitation: Knowledge and opinions among the U.S. general public. State of the science-fiction. Resuscitation, 79, 490-498.

Commentary by Dana N. Rutledge, RN, PhD, Nursing Research Facilitator

This interesting study, published in 2008, features data collected in 2000. This is disappointing considering the factors that may have changed since 2000. The researchers surveyed people in airport and bus terminals, hospital waiting rooms, shopping malls, and college campuses in Pennsylvania and Ohio. The participants – while closely resembling the data from the U. S. census – may under-represent Hispanic persons, and over-represent older, single, and highly educated persons who are mobile.

It is interesting to note that respondents overestimated success rates for resuscitation results, and that 91% of them were willing to undergo CPR. However, smaller proportions would find the following procedures acceptable:
 74% chest compressions
 64% mouth-to-mouth breathing
 61% electrical shocks (defibrillation)
 54% intravenous medications
 42% artificial breathing on a respirator
 31% large intravenous lines in the neck or groin
This indicates understanding deficits as to what “resuscitation” actually involves!

Anyone interested in replicating the study with our patients and families? The survey used is published with the article, and is available in Spanish.

Vickie's Research Corner

2009-09-17T12:51:00.000-07:00

View my guestbookCan you believe it? Fall is here and the weather is changing. Things at St. Joseph are changing just like the seasons and the new buzz word is Evidence-Based Practice (EBP). As we continue in our journey as a Magnet organization, EBP is pushing its way into the practice of nurses throughout the hospital. Over the past year I have begun to introduce you to our new Clinical Nurse EBP Experts. These are Clinical Nurse III/IV nurses who took an intensive 4 day class to become more familiar with EBP and how this impacts their practice as well as yours. This issue I would like to introduce you to Rashna Thakur and Ellen Gruwell.
Rashna is Clinical Nurse III and works in the Pediatric Renal Center. She has been at this hospital since 1996. She became a Clin III 2 years ago. When asked why she wanted to become an EBP expert she responded that she had no clue what a Clinical Nurse EBP Expert initially was and was encouraged by Ann Marie Keefer-Lynch to apply for the program. Initially when taking the course she felt a rookie in the crowd because everyone else knew about EBP. After taking the course she realized that EBP was great. Knowledge was eye opening! She learned what EBP is and who does it. She now understands how to look for research and apply EBP at the bedside. Rashna feels much more aware of evidence and how we use it. She now makes changes in her practice based on evidence, not tradition.
Taking the class encouraged her to accomplish several goals. Now nurses are cross-training from primarily pediatrics to adults and she helped create the new policy based on EBP. She was able to take what she learned and put it into practice. Rashna was no longer the rookie in the crowd who didn’t understand EBP!
Our second Clinical Expert is Ellen Gruwell. She has been a nurse in the St. Joseph Health system since 1981. Initially she worked for St. Jude and then in 1987 came to SJH. Currently she works in Labor and Delivery as a Clinical Nurse III. Ellen felt that her masters program at California State University Fullerton and meeting Dana Rutledge made the biggest difference in her life for wanting to learn more about EBP and Research, so she decided to become a Clinical Expert.
For Ellen, she learned that there is a lot of buy in for EBP from nursing. It seems that since she has become an expert she is getting the “lingo” out there and the nurses are starting to change their practice and base their decisions on EBP. Her own practice has changed significantly because she is now more excited about potential research that can be done in Women’s Health Services. She feels nursing is a science and needs to be based in science!
She is now looking at car seats a late preterm infant safety when they go home. She is also interested in identifying how nurses cope in labor and delivery.
Both nurses were from very different areas but both were changed by the world of evidence-based practice and both are changing practice at the bedside!

Our Magnet Journey to Redesignation

2009-09-16T14:23:00.000-07:00

The Magnet Recognition Program is the nation’s highest honor for nursing and recognizes excellence in Leadership, Practice, and Patient Outcomes. This prestigious award is administered by the American Nurses Credentialing Center (ANCC), who provides individuals and organizations throughout the nursing profession with the resources they need to achieve practice excellence.

To achieve Magnet status, a hospital must demonstrate a culture of excellence in nursing care as well as sustain and demonstrate the 14 Forces of Magnetism in the practice of nursing. The facility must also foster a nursing environment that is exciting, supportive, and intellectually stimulating.

The Magnet Recognition program focuses on advancing 3 goals within each applicant designee:
* Promoting quality in a setting that supports professional practice
* Identifying excellence in the delivery of nursing services to patients
* Disseminating “best practices” in nursing services

The Next Generation of Magnet:
The 14 Forces of Magnetisms have been redesigned and integrated into The 5 Model Component. This allows for a more focused approach and decreased redundancy. With the 14 Forces as the foundation, the 5 Model Components will be the primary basis for achieving Magnet recognition.

St. Joseph Hospital's Journey continues as we move forward with our gathering of evidence. The Steering Committee and Magnet Ambassadors are currently in the process of accruing and submitting data in their respective component groups. This data will be reviewed and placed in the most appropriate area within the Magnet documents we will submit next year. More to come on our progress...

New article published by staff at St. Joseph Hospital, Orange

2009-09-16T11:39:00.000-07:00

Congratulations to Beth (Elizabeth) Winokur, RN, MSN, CEN and John Senteno, RN, MSN, CEN from St. Joseph Hospital in Orange, California on their recent publication in the September issue of Journal of Emergency Nursing.

Winokur EJ, Senteno JM. Guesting area: an alternative for boarding mental health patients seen in emergency departments. J Emerg Nurs. 2009Sep;35(5):429-33. Epub 2008 Oct 17. PubMed PMID: 19748023.

Staff at St. Joseph Hospital, Orange and Children's Hospital of Orange County can read the full text of this article through the link to Journal of Emergency Nursing on the library's website.

2009-09-04T10:18:00.000-07:00

The following article appeared in Working Nurse v. 90 Aug 24, 2009 on Nursing Research at St. Joseph's

By Beth Duggan
Have you ever wondered why a procedure is done a certain way? Or why a certain action is taken? If your answer is, “Because it’s always been done that way,” then you’d benefit from a little nursing research.
Not clear on what that is? Let Dana Rutledge, RN, Ph.D., facilitator of the Office of Nursing Research at St. Joseph, enlighten you.
“Nursing research involves multiple steps,” she said. “Thinking of the research question, reviewing the literature to see what else is known on the topic, developing a research plan, seeking approval from the institutional review board, collecting data, analyzing data, and disseminating the results through a written report or poster.”
According to Ms. Rutledge and her assistant, Vickie Morrison, RN, MSN, FNP, this kind of research is important because the results offer a chance to improve patient outcomes. And nurses who stay current about evidence in their area are more likely to use best evidence.A Culture of Inquiry
St. Joseph’s nursing research department started in June 2004 as the hospital began its journey toward magnet status. Lacking a Ph.D.-prepared nurse who could conduct the research, they brought in Ms. Rutledge, who is also a professor in the nursing department at California State University, Fullerton.
Through her facilitation and the work of Ms. Morrison, the research office has, according to the staff, “led to a culture of inquiry, and the desire to base nursing care practices on best evidence.” Inquiring nurses at St. Joseph have been performing both evidence-based practice changes and research, and some have even submitted abstracts to conferences for podium and poster presentations about projects that have been completed.
One such case was a group of nurses in the ambulatory post-anesthesia care unit. Their research found that patients were not fully prepared for their surgical experience, which led to changed materials sent to physicians’ offices and phone calls made to patients before their procedure to help them feel more prepared. The results were presented as a poster at a regional conference.
The two nurses say the biggest challenge in their work has been getting word out that there is a Nursing Research Office, so in 2007 they visited almost all the departments in the hospital that employ nurses to discuss what the Office of Nursing Research does and to find out what questions nurses have about their own practice.
The success of that initiative has bred more success for the office, which means juggling multiple projects at once.
“Right now we have two manuscripts to nursing journals that we submitted with study results, both of which require revisions,” said Ms. Morrison. “We have four newly approved studies that are in the beginning phases of data collection; we have two studies that are ready for data analysis; and the rest are all in the data collection phase. Then there are three groups of nurses who are in the preparation phases.”Evidence-based Blog
In March 2006, Julie Smith, MLS, AHIP, the medical librarian at St. Joseph, wanted to give a unique contribution and enhance the arena of EBP and nursing research. This led her to the Internet, where she developed a blog http://evidencebasednursing.blogspot.com dedicated to “bringing awareness to current nursing literature, conferences, resources and tutorials.”
The first team nursing blog dedicated to EBP and research, it is full of useful information such as how to read research articles, how to create a poster for dissemination, and new information on EBP. It also gives tips for searching on St. Joseph’s and Childrens Hospital Orange County’s research databases. To date the site has received approximately 71,000 hits, which averages to 102 daily and 3,060 each month.
“Evidence-based practice in nursing is constantly changing with new research and new evidence,” Ms. Rutledge said. “The most important significance for EBP is the fact that nurses are learning how to use evidence at the bedside to improve patient outcomes. EBP provides a solid foundation for nursing to change practice in a manner that is systematic and credible.”
Beth Duggan is the editor of Working Nurse.

Vitamin D- the new wonder drug??

2009-09-03T10:12:00.000-07:00

The September issue of The American Journal of Medicine (Volume 122, Issue 9) has an extensive review of the research on the benefits of Vitamin D. The article notes that over 1/2 of the world's population is Vitamin D deficient. We used to think that Vitamin D was only important for healthy bones but recent research has shown that Vitamin D affects our health in many other ways.
Vitamin D is important in bone health- one study showed that given 800iu/d of Vit D- persons aged 65-85 years of age had 1/3 reduced fracture risk.
Vitamin D is also needed for muscle development and function- one study has shown a 22% decrease in falls related to improved neuromuscular function with Vitamin D supplementation. Vitamin D is found to decrease muscle degeneration and increase reaction time and motor response which also decreases fall and therefore fracture risk.
Vitamin D has also been linked to chronic pain. Numerous studies have tied low levels of vitamin D to persistent musculoskeletal and neuropathic pain. Persons with chronic pain that has no obvious cause should be tested vitamin D deficiency.
Vitamin D is involved in the immune response and autoimmune diseases. Research has found a 40% lower risk of multiple sclerosis in women taking vitamin D supplements. Lupus and rheumatoid arthritis symptoms are more severe in those who are vitamin D deficient.
It seems that Vitamin D influences insulin sensitivity and beta cell function as well. Up to a 60% increase in insulin sensitivity was found in persons with greater than 30ng/ml serum vitamin D levels compared with those that have less than 10ng/ml. One study showed an 80% decreased risk of developing diabetes type 1 in children supplemented with 2000 iu/d of vitamin D in the first year of life. These children were followed for 20 years.
It appears that vitamin D is also involved in brain function. Older adults with low vitamin D levels performed worse on the mini mental status exam and showed more memory problems and depression than those with normal vitamin D levels. One large study found a correlation with depression severity and low vitamin D levels.
Some studies show a decrease in cancer risk and mortality associated with vitamin D. Vitamin D has been found to be antiproliferative, promote cell differentiation, and induce apoptosis, among other anti-cancer properties. Numerous studies have shown benefit in prevention and mortality in colorectal cancer, pharyngeal cancer and leukemia, as well as decreased breast cancer risk and decreased mortality from melanoma.
There is evidence that vitamin D has a role in cardiovascular health. Vitamin D is thought to influence the reticular activating system, vascular calcification, smooth muscle proliferation, and inflammation. Studies suggest that vitamin D deficency is an independent risk factor for myocardial infarction in men. Higher vitamin D levels are shown to decrease vascular calcification. Due to it's potent effect on vascular endothelial cells- vitamin D can lower blood pressure. It also seems to have a role in preventing cardiomyopathy- at least in hemodialysis patients.
All cause mortality is decreased by at least 7% in a meta-analysis of 18 randomized trials of vitamin D supplementation.
What do we do now?
Serum Vitamin D levels can by checked by ordering a 25(OH)D serum analysis. A result of 30ng/ml is considered normal although due to variations in laboratory results the current recommendation is to aim for 35-40ng/ml as an optimum level. Some suggest that all individuals be screened for vitamin D levels.
While we synthesize vitamin D from sun exposure- it is not recommended due to skin cancer risk and photoaging effects on the skin. Oral supplementation in the form of vitamin D3 is most effective. While dosage recommendations vary- from 200IU per day and up- it is safe to take larger doses- so1000-3000IU/d may be recommended in the near future.
Clearly there is overwhelming evidence that vitamin D deficiency is widespread and that suppplementation is inexpensive and highly beneficial. For more information refer to the original article and the 108 references that accompany it.

Cancer Research in Breast Cancer

2009-09-03T08:25:00.000-07:00

Cancer Research in Breast Cancer Patients

St. Joseph Hospital performs more clinical trials than any other community hospital in Orange County. And, continued advances in cancer care and prevention are the direct result of participation in clinical trials. National evidence from a wide range of studies suggests that cancer patients diagnosed and treated in a setting of multi-specialty care and clinical research may live longer and have a better quality of life.

As a participant in the NCI Community Cancer Centers Program (NCCCP) Pilot, The Center for Cancer Prevention and Treatment is committed to offering residents of Orange County, Southern California and beyond access to research-based cancer care. By expanding clinical trials and cancer care we hope to make it easier to receive high-quality cancer screening, prevention, treatment and palliative care services.

Clinical trials that are well designed and well executed are the best approach for eligible participants to:

Play an active role in their own health care.
Gain access to new research treatments before they are widely available.
Obtain expert medical care at leading health care facilities during the trial.
Help current and future cancer patients by contributing to medical research.

What are the different types of clinical trials?

Treatment trials test experimental treatments, new combinations of drugs or new
approaches to surgery or radiation therapy.

Prevention trials look for better ways to prevent disease in people who have never had the
disease or to prevent a disease from returning. These approaches may include medicines,
vaccines, vitamins, minerals or lifestyle changes.

Diagnostic trials are conducted to find better tests or procedures for diagnosing a particular
disease or condition.

Screening trials test the best way to detect certain diseases or health conditions.

Quality of Life trials (or Supportive Care trials) explore ways to improve comfort and the
quality of life for individuals with a chronic illness.

As the Nurse Navigator for the Breast Program, I am excited to announce that the Research department at the Center for Cancer Prevention and Treatment has recently opened the 9th and 10th clinical trial for breast cancer patients. It is part of my responsibility as the Nurse Navigator for the Breast Program to serve as a reliable source of information about available research trials. I also serve as a vital link for cancer research by demonstrating familiarity with available program-specific trials, the associated eligibility and exclusion criteria, and the informed consent content and process. I assist the Research Department with communication and coordination of required research information, as needed and provide routine updates on patient status with the managing physician and the Cancer Research Department.

The following are a list of the clinical trials we have available at this time:

NSABP B-40 (Neo-Adj): A Randomized Phase III Trial of Neoadjuvant Therapy in Patients with Palpable and Operable Breast Cancer Evaluating the Effect of Pathologic Complete Response.

NSABP B-41 (Neo-Adj): A Randomized Phase III Trial of Neoadjuvant Therapy for Patients with Palpable and Operable HER2-Positive Breast Cancer.

ACOSOG Z1031 (Stage II-III Neo-Adj): A Randomized Phase III Trial in Postmenopausal Women w/ Clinical Stage II and III Estrogen Receptor Positive Breast Cancer.

Dune Medical Devices (DCIS): Margin Probe, a Device for Intraoperative Assessment of Margin Status in Breast Conservation Surgery.

NSABP B-43 – (DCIS - NCCCP PRIORITY TRIAL):
A Phase III Clinical Trial Given Concurrently with Radiation Therapy and Radiation Therapy Alone for Women with HER2-Positive Ductal Carcinoma In Situ Resected by Lumpectomy.

NSABP B-39 (Stage 0-II): A Randomized Phase III Study of Conventional Whole Breast Irradiation (WBI) versus Partial Breast Irradiation (PBI) for Women with Stage 0, I, Or II Breast Cancer.

ECOG PACCT-1 (Adjuvant NCCCP PRIORITY TRIAL): Program for the Assessment of Clinical Cancer Tests (PACCT-1): Trial Assigning Individualized Options for Treatment.

Endurance Exercise (Stage 0-II): Effects of Endurance Exercise on Bio-behavioral Outcomes of Fatigue - A Pilot Study.

NSABP B-42 (Stage I-IIIA NCCCP PRIORITY TRIAL): A Clinical Trial to Determine the Efficacy of Five Years of Letrozole Compared to Placebo in Patients Completing Five Years of Hormonal Therapy Consisting of an Aromatase Inhibitor (AI) or Tamoxifen Followed by an AI in Prolonging Disease-Free Survival in Postmenopausal Women with Hormone Receptor Positive Breast Cancer.

NSABP B-46-I (Stage I-IIIB): A Phase III Clinical Trial Comparing the Combination of TC Plus Bevacizumab to TC Alone and to TAC for Women with Node-Positive or High-Risk Node-Negative, HER2-Negative Breast Cancer.

For more information about clinical trials for breast cancer, please contact Stacey Fischer, RN, BSN, OCN, Nurse Navigator for the Breast Program at (714)734-6233 or the Research Department at the Center for Cancer Prevention and Treatment at (714)734-6200.

Learning from research on the information behaviour of healthcare professionals: a review of the literature ...with a focus on emotion

2009-08-28T15:09:00.001-07:00

Just came across this fascinating article ( at least to me): Learning from research on the information behaviour of healthcare professionals: a review of the literature 2004- 2008 with a focus on emotion. Fourie, Ina. Health Information & Libraries JournalVolume 2009 26(3):171 - 186. This study is a very detailed analysis of the scant literature on the role that "emotion" plays in health provider's information seeking behavior. Emotion goes way beyond what we might initially think and extends to include nine identified themes. Just a few of these 9 identified themes include: "difficulty in identifying and expressing information needs and information behavior", "uncertainty and anxiety", the role that personality and coping skills play and the role that self confidance and attitude play. The author even offers a detailed table with a large number of suggestions as to how Library and Information Science(LIS) professionals might impact or ameliorate the information seeking barriers of "emotional issues". One quote that really resonated with me from MacIntosh-Murrray and Choo in their article "Information behavior in the context of improving patient safety" Journal of the American Society for Information Science and technology 2005 56:1332-1345 "...front line staff are task driven, coping with heavy workloads that limit their attention to and recognition of potential information needs and knowledge gaps" However, a surrogate in an information-related role, an "information/change agent"-may intervene successfully with staff ..." What do you all think? any innovative ways in which librarians can better play this role as an information surrogate?

Don't Miss our Annual EBP Conference, October 2

2009-08-26T17:00:00.000-07:00

Please join us for the St. Joseph Hospital 5th Annual Evidence-Based Practice Conference, “Evidence Based Approaches to Infection Prevention and Management” on Friday, October 2 from 8-4:30pm at St. Joseph Center, Orange, Ca. This 8-hour course will include various speakers from St. Joseph Hospital as well as from local healthcare agencies.

Topics will include: Influenza, HealthCare Associated Infections, Current Legislation, Biofilm, Community Trends in TB and others.
This annual conference has been one of our best attended classes of the year and will prove to be another interesting and educational event. Learn the latest and improve your clinical practice!
Registration is NOW available for St. Joseph Hospital Employees through our new on-line registration through CareNet.

For those interested from outside St. Joseph Hospital, please call the Clinical Education Department for further information about registration at (714) 771-8000, extension 17345. Cost for the entire day is $75.00. Space is limited and early registration is recommended.

Journal of Nursing Administration devotes current supplement to "Magnet"topics

2009-08-17T16:46:00.001-07:00

The July/August 2009 supplementary issue of Journal of Nursing Administration is devoted entirely to "The Evidence for
Magnet® Status". Articles that look especially interesting include: "Workplace Empowerment and Magnet Hospital Characteristics as Predictors of Patient Safety Climate" and "Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes". Employees of St. Joseph Hospital, Orange and CHOC may access the full text of the articles via the library's website. Others should contact the medical library at your institution.

New review regarding the benefits of Fish Oil!

2009-08-12T16:27:00.000-07:00

On August 3, 2009 the Journal of the American College of Cardiology published a paper reviewing the evidence of the benefits of fish oil or Omega-3 polyunsaturated fatty acids (PUFAs).

The findings support the use of fish oil for everyone- not just heart patients! The evidence supports that fish oil prevents as well as treats cardiovascular disease. Fish oil has been found to prevent heart failure as well as decrease hospitalization and death in both heart failure and post-MI patients. It has shown to reduce arrhythmias as primary and secondary prevention- particularly in atrial fibrillation (AF). Fish oil also helps to prevent atherosclerosis and there is data to suggest it helps in hyperlipidemia.

The optimal dose of fish oil- as measured by EPA/DHA is at least 500 mg per day for prevention and 800-1000mg per day for those with known heart disease. This can be accomplished with supplements or eating fatty fish such as salmon, tuna, mackerel, or sardines. Healthy persons would need 2 servings per week while heart patients would require 4 or 5 fish servings per week.

Further study is needed to determine optimal mix of EPA to DHA and mechanisms of action in arrhythmias, atherosclerosis and primary myocardial disease. The abstract of the paper is free at http://content.onlinejacc.org/cgi/content/abstract/54/7/585 and a synopsis of the article is available at the heart.org then go to heartwire( you must sign in for a free membership) to access the article dated 8/10/09.

Research Abstract and Commentary: Topical Opioids

2009-08-12T08:49:00.000-07:00

Effectiveness of Topical Administration of Opioids in Palliative Care: A Systematic Review [Authors' Abstract].
The discovery of peripheral opioid receptors has become the scientific basis for topical use of opioids in malignant and nonmalignant ulcers and oropharyngeal mucositis. This systematic review aimed to assess the quality of published literature and to examine whether topical opioids are effective in controlling pain in palliative care settings. After a systematic literature review, 19 studies (six randomized controlled trials [RCTs] and 13 case reports) met the inclusion criteria for the review. Eighteen studies favored topical opioids in pain relief, as evidenced by reductions in post-treatment pain scores, but time to onset and duration of analgesia varied widely. Because of the heterogeneity of the studies, meta-analysis was not possible. Despite clear clinical benefits described in small RCTs, there is a deficiency of higher-quality evidence on the role of topical opioids, and more robust primary studies are required to inform practice recommendations. N-of-1 trials should be encouraged for specific clinical circumstances.

LeBon, B., Zeppetella, G., & Higginson, I. J. (2009). Effectiveness of topical administration of opioids in palliative care: a systematic review. Journal of Pain & Symptom Management, 37, 913-7.

Commentary by Dana Rutledge

The clinical problem of painful skin and mucosal lesions is a challenge in all settings, but particularly in palliative care where systemic opioids may not be sufficient for pain relief or where patients may resist systemic opioids due to unfavorable side effects. This systematic review used the Centre for Evidence-Based Medicine methods, and was done appropriately, although the last search for primary studies was done in August 2006 and the publication date is May 2009 (a long window of time for newer studies to have been published).
Findings showed that topical opioids were used for both malignant and nonmalignant wounds as well as oropharyngeal mucositis. Applications for skin wounds were 1-6 times daily and every 2-3 hours for mouthwashes. Opioids were administered in a variety of carriers (e.g.., hydrogel). The primary finding was pain relief following use of topical opioids. Secondary findings indicated that 0.1% diamorphine (heroin) led to pain relief in one hour with duration between 24 and 48 hours, while topical morphine relieved pain immediately to 60 minutes after administration and lasted 2 to 45 hours in ulcers and one to four hours in mucositis.
Scarce reports were found related to adverse effects. Primarily reported were local effects such as itching, burning, and discomfort. Possible administration problems existed with exudates and possible tolerance with prolonged usage.
Due to the intrinsic difficulties with studies in palliative care patients (heterogeneity, low recruitment, high drop out rates), the authors recommended N of 1 trials. In N of 1 trials, a single subject receives a treatment or placebo in a randomly assigned order; data are collected on outcomes to determine effect in this one patient. For example, a palliative care patient with a wound might be set up to receive 6 days of treatment (3 days of a topical opioid/3 days of placebo; order determined in a random manner) with pain monitored carefully for severity, onset of pain relief, adverse effects etc.

New Cochrane study: Reducing blood pressure below 140/90 brings no clinical benefit

2009-08-03T08:45:00.000-07:00

Cochrane reviews are considered by most to be the Gold standard in evidence based medicine. This resource is updated every three months and now has nearly 20,000 voluntary reviewers. As such, the Cochrane systematic reviews have a well deserved global reputation. One of the newest reviews that is getting a lot of press is Treatment blood pressure targets for hypertension. This study is particularly important as so many guidelines are recommending even lower blood pressure targets. The summary in this review states: "Main results No trials comparing different systolic BP targets were found. Seven trials (22,089 subjects) comparing different diastolic BP targets were included. Despite a -4/-3 mmHg greater achieved reduction in systolic/diastolic BP, p<>Authors' conclusions .Treating patients to lower than standard BP targets, ≤140-160/90-100 mmHg, does not reduce mortality or morbidity. Because guidelines are recommending even lower targets for diabetes mellitus and chronic renal disease, we are currently conducting systematic reviews in those groups of patients. "

SJO/CHOC library users can access the full Cochrane report through the library's web site: http://www.burlewmedicallibrary.org

compilation of 90+ videos on technology and media literacy

2009-07-24T10:14:00.001-07:00

I have just come across a very cool podcast site which has made an excellent compilation of videos ( mostly youtube) available to anyone as education tools on the topics of technology and media literacy. More than 90 links to videos are freely available and would be excellent additions to education presentations. Kudos to Dr. Alec Couros, a professor of educational technology and media at the Faculty of Education, University of Regina who created EdTech Posse .

Clinical Narratives

2009-07-22T16:54:00.000-07:00

Clinical Narratives are nurse stories of caring. At St. Joseph Hospital, clinical narratives are submitted to the Clinical Development Council as part of the Clinical Advancement process to move up the ladder from Clinical Nurse II to Clinical Nurse III (CN III) or Clinical Nurse IV (CN IV). As each proficient (CN III) and expert (CN IV) comes before the Clinical Development Council for advancement, they read their narrative aloud and have an opportunity to answer questions. The richness of their stories are shared.
The clinical narratives are also written by New Grads during the New Grad program. These narratives are submitted to the Clinical Development Council anonymously, and as we read them, we identify themes. The themes help to define nursing practice at St. Joseph Hospital. Over the years, the themes identified have opened up dialog and changes in our practice.
The Clinical Nurse IIs (CN II) are asked to write narratives during the months of July and August. The majority of RN’s at St. Joseph Hospital are CN IIs, but we tend to get fewer narratives from the CN IIs. In an attempt to encourage the CN IIs to write their stories, we are trying something new: Clinical Narrative Mentoring sessions. We are hoping that offering encouragement and 1:1 writing assistance will help to bring forth more nurse stories to share. I suppose the motivation to write a narrative is less for the CN IIs than the rest of the nurses, and as a consequence, we are missing hearing the voice of the majority of our wonderful nurses.

AHRQ Evidence-Based Practice Update

2009-07-22T08:12:00.000-07:00

The U.S. Preventive Services Task Force, which is part of the Agency for Healthcare Research and Quality, recently posted a report entitled : The U.S. Preventive Services Task Force : An Evidence-Based Prevention Resource for Nurse Practitioners.
According to the abstract "Purpose: To describe the work of the U.S. Preventive Services Task Force and to encourage nurse practitioners (NPs) to use its evidence-based recommendations for clinical preventive services.
Sources: Evidence reports, recommendation statements, and journal articles published under the auspices of the U.S. Preventive Services Task Force since its establishment in 1984.
Conclusions: A core competency for NPs working in primary care is knowledge about and provision of appropriate preventive services for their patients. The U.S. Preventive Services Task Force, an independent panel of experts in prevention and primary care, is an important resource for NPs.
Implications for Practice: NPs can use Task Force recommendations to guide their screening, counseling, and preventive medication decisions. They can also educate patients about the missed prevention opportunities related to underuse of effective services and the potential harms of overuse of inappropriate preventive services.
Keywords: Advanced practice nurse (APN); primary care; prevention, clinical practice guidelines; evidence-based practice.Purpose: To describe the work of the U.S. Preventive Services Task Force and to encourage nurse practitioners (NPs) to use its evidence-based recommendations for clinical preventive services.
Sources: Evidence reports, recommendation statements, and journal articles published under the auspices of the U.S. Preventive Services Task Force since its establishment in 1984.
Conclusions: A core competency for NPs working in primary care is knowledge about and provision of appropriate preventive services for their patients. The U.S. Preventive Services Task Force, an independent panel of experts in prevention and primary care, is an important resource for NPs.
Implications for Practice: NPs can use Task Force recommendations to guide their screening, counseling, and preventive medication decisions. They can also educate patients about the missed prevention opportunities related to underuse of effective services and the potential harms of overuse of inappropriate preventive services."

Trinite T, Loveland-Cherry C, Marion L. U.S. Preventive Services Task Force: An Evidence-based Prevention Resource for Nurse Practitioners. Originally published in Journal of the American Academy of Nurse Practitioners 21(2009):301-306. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf09/epbnursep/epbnursep.htm

Survivorship Education for Quality Cancer Care

2009-07-20T10:31:00.000-07:00

Survivorship Education for Quality Cancer Care
News Release for Participants of SEQCC
Disseminating Survivorship Education to Cancer Settings

Interdisciplinary teams of physicians, nurses, social workers, and other health professionals such as psychologists, radiation technologists, chaplains, and administrators are involved in the multitude of treatment options for cancer patients during the course of their illness. These professionals however are inadequately prepared to meet the follow up needs of cancer survivors.

I recently attended a comprehensive three-day course for interdisciplinary teams from cancer settings on survivorship care. The City of Hope (COH) Comprehensive Cancer Ceneter received a 5-year grant from the National Cancer Institute to conduct this course. The project is led by Marcia Grant, RN, DNSc, FAAN, principal investigator, Betty Ferrell, RN, PhD, FAAN, and Smita Bhatia, MD co-investigators, and Denise Economu, RN, MN, CNS, project director.

I was one of over 2-person teams from 53 institutions competitively selected from cancer settings across the United States to attend this course. The prinicipal goal of the course is to provide interdisciplinary teams with information on survivorship care issues and resources to implement goals aimed at improving survivorship care in their cancer institutions.

The course was conducted by a distinguised faculty of researchers, educators, authors, and leaders in the field of survivorship care. Topic areas targeted the recommendations from the 2006 Institute of Medicine report, "From Cancer Patient to Cancer Survivor-Lost in Transition." State of the Science lectures addressed quality of life decisions and identified areas of need for survivorship care as well as issues related to insurance coverage, developing survivorhsip clinics and quality care issues. Additional questions or information about future courses can be directed to deconomou@coh.org.

Robert Wood Johnson Foundation, Institute of Medicine Launch Unprecedented Initiative on the Future of Nursing in America

2009-07-14T14:24:00.001-07:00

Robert Wood Johnson Foundation, Institute of Medicine Launch Unprecedented Initiative on the Future of Nursing in America

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3 new search engines compared:Wolfram/Alpha, Bing and Google Squared

2009-07-06T14:54:00.000-07:00

Kudos to the Disrupted Library Technology Jester for doing an excellent comparison of 3 new search engines: Wolfram/Alpha, Microsoft's new Bing and Google squared

Bing is the most like existing search engines whereas the other two search engines are
geared to "fact retrieval". I'm sure you've all seen a lot about these new search engines in
the media but this review is particularly well written and easy to follow.

Check it out!!

Top 50 Nurse Practitioner blogs; we're represented!

2009-07-02T07:59:00.000-07:00

Kudos to the Online Nurse Practitioner Schools site for pulling together an excellent list of the top 50 Nurse Practitioner blogs. Besides seeing our own blog listed, I have learned of several blogs that I'd like to follow including Running a hospital a blog by Paul Levy who is President and CEO of Beth Israel Deaconess Medical Center in Boston .

H.R. 2824 bill on federal support for comparative effective research

2009-06-24T09:07:00.000-07:00

Nursing should be aware of the current Federal Bill H.R. 2824 in support of federally funded comparative effectiveness research. A recent NY Times article gives a good description of this. This potentially has a lot of implications for nursing research.

Say hello to our new blog team

2009-06-17T12:32:00.001-07:00

Say hello to our new nursing research blog team!! From left to right are: Kathy Dureault, Stacey Fischer, Victoria Morrison, Dana Rutledge, Vivian Norman and Julie Smith. Not pictured is Theresa Ullrich. We are looking forward to active participation and lots of new blogging from our new team members.

Smoking and Alcohol Intervention before Surgery: Evidence for Best Practice

2009-06-10T14:33:00.000-07:00

Research Abstract and Commentary

Smoking and hazardous drinking are common and important risk factors for an increased rate of complications after surgery. The underlying pathophysiological mechanisms include organic dysfunctions that can recover with abstinence. Abstinence starting 3–8 weeks before surgery will significantly reduce the incidence of several serious postoperative complications, such as wound and cardiopulmonary complications and infections. However, this intervention must be intensive to obtain sufficient effect on surgical complications. All patients presenting for surgery should be questioned regarding smoking and hazardous drinking, and interventions appropriate for the surgical setting applied.

Tonnesen, H., Nielsen, P. R., Lauritzen, J. B., & Moller, A. M. (2009). Smoking and alcohol intervention before surgery: Evidence for best practice. British Journal of Anaesthesia, 102, 297-306.

Commentary by Dana Rutledge, RN, PhD

In this article, Tonnesen and colleagues systematically reviewed literature on the effects of smoking on postoperative pulmonary and wound complications and the effect of hazardous drinking (2-3 drinks/day) on postoperative morbidity. Their review used a research or review method called meta-analysis, whereby reviewers analyze results from individual studies in order to integrate or synthesize results as a whole. Figure 1 below shows their findings regarding the complications found associated with smoking and alcohol for all types of surgeries, in all settings.

The authors then reviewed literature on the effects of preoperative interventions (smoking/alcohol cessation) to evaluate effects on postoperative outcomes. They found that smoking interventions are most likely to enhance wound healing and pulmonary complications, and that they could not state what the “optimal” length or duration of smoking cessation necessary to guarantee success. However, Tonnesen and colleagues found that even short-term interventions led to positive results (on average).

Alcohol cessation interventions are less clear in terms of effect since alcohol use is often not defined similarly across studies, and interventions differ. However, based upon the studies reviewed, Tonnesen et al. support interventions that lead to even short-term abstinence because liver and other organ dysfunction improves after 1-2 weeks of alcohol abstinence.

Based upon these findings and the fact that about 80% of pre-operative patients want help in changing their lifestyle prior to surgery, Tonnasen et al. recommend the following:
• Patients should be screened pre operatively for tobacco and alcohol use in order to determine whether they are daily or non-daily smokers and hazardous (> 2-3 drinks daily) or non hazardous drinkers. This identifies high- and low-risk patients.
• Interventions should be carried out between the referral date for surgery and the date of the operation.
• For both smokers and hazardous drinkers, weekly individual counseling enhances preoperative cessation. Smoking cessation programs from 3-8 weeks may be successful and must include personalized nicotine substitution schedules, diaries of tobacco consumption, advice on smoking cessation, benefits and side-effects, how to manage withdrawal symptoms and weight management strategies. Length of alcohol cessation programs varies but should include personalized alcohol withdrawal symptom treatment, supportive medications, diaries of alcohol intake, advice about alcohol cessation, benefits and side-effects, and management of withdrawal symptoms.

This article documents systematic development of evidence-based recommendations about preoperative care of patients. Nurses at St. Joseph who counsel patients undergoing surgeries should be aware of these recommendations, and help their patients seek smoking and alcohol cessation programs to assist them in preparing for surgery.

Figure 1. Postoperative complications associated with smoking and alcohol use
Postoperative complications attributed to smoking
• Impaired wound and tissue healing
• Wound infection
• Cardiopulmonary complications
Postoperative complications attributed to alcohol
• Postoperative infections
• Cardiopulmonary complications
• Bleeding episodes