Maxson, Pamela M.

Background Nursing handoff is a communication activity with a high risk for loss or omission of information. Efforts to improve handoffs include standardization of the processes and content of handoff communications. Objectives To examine nurses’ perspectives on the structure and organization of change-of-shift handoffs. Methods A qualitative descriptive approach was used to conduct a secondary analysis of focus group data. Thirty-four nurses from 4 critical care units participated in focus groups. Results Three themes emerged: handoff elements are defined by practice and culture; a clear, consistent, identified structure supports handoff; and personal preferences can disrupt handoff. Conclusions A standardized approach to handoff based on unit and organizational needs will be more successful than a broad mandate of content and organization. Individual preference is prevalent and strongly influences the information conveyed and the structure of handoff communication.

AbstractBackgroundThe importance of change‐of‐shift handoffs in maintaining patient safety has been well demonstrated. Change‐of‐shift handoff is an important source of data used in surveillance, a nursing intervention aimed at identifying and preventing complications. Surveillance requires the nurse to acquire, process, and synthesize information (cues) encountered during patient care. Interruptions in handoff have been observed but there is a gap in the evidence concerning how interruptions during nurse‐to‐nurse handoff impact the change‐of‐shift handoff process.AimsTo describe registered nurses’ perceptions of interruptions experienced during change‐of‐shift handoff at the bedside in critical care units and analyze the number, type, and source of interruptions during change‐of‐shift handoff at the bedside.MethodsAn exploratory descriptive design was used. One hundred nurse‐to‐nurse handoffs were observed, and four focus groups were conducted. Observation data were analyzed with descriptive statistics and quantitative content analysis. Focus group data were analyzed with qualitative content analysis.Results and FindingsOf the 1,196 interruptions observed, 800 occurred in the communication between the two nurses involved in the handoff. Over 80% (645) of these interruptions were from the nurse receiving handoff and included questions or clarification of information received. About half of the nurses reported that interruptions occurred during handoff. Focus group findings revealed that whether or not something is an interruption is determined by the individual nurse’s appraisal of value added to their knowledge of the patient and/or plan of care at the time of handoff.Linking Evidence to ActionInterruptions during handoff are evaluated as useful or disruptive based on the value to the nurse at the time. Strict structuring or mandating of handoff elements may limit nurses’ ability to communicate information deemed most relevant to the care of a specific unique patient.

This review provides an update on the treatment of benign prostatic hyperplasia and the pharmacologic considerations for perioperative care. By age 85 years, approximately 90% of men have prostate histologic characteristics consistent with benign prostatic hyperplasia. Pharmacologic treatment with an alpha 1 receptor antagonist may reduce symptoms and, when given in combination with a 5-alpha-reductase inhibitor, may decrease the risk of urinary retention and the need for surgical intervention. Transurethral resection of the prostate has been the historical standard when surgical intervention is indicated. However, recent evidence suggests that Holmium laser enucleation of the prostate may have similar efficacy with less risk of complications and with decreased catheterization time. Prostatic urological operations may have perioperative complications, including urethral bleeding, acute urinary retention, urinary tract infection, urge incontinence, and venous thromboembolism. Pharmacist recommendations for the appropriate use of laxatives, antibiotics, anticoagulation, and urinary antispasmodics are key components of perioperative management. Surgical interventions improve symptoms but may have complications, providing the pharmacist an opportunity to improve perioperative care.

Abstract Background Accelerated recovery pathways may reduce length of hospital stay after surgery but there are few data on minimally invasive colorectal operations. Methods An enhanced recovery pathway (ERP) was instituted, including preoperative analgesia, limited intravenous fluids and opiates, and early feeding. Intrathecal analgesia was administered as needed, but epidural analgesia was not used. The first 66 patients subjected to the ERP were case-matched by surgeon, procedure and age (within 5 years) with patients treated previously in a fast-track pathway (FTP). Short-term and postoperative outcomes to 30 days were compared. Results Hospital stay was shorter with the ERP than the FTP: median (interquartile range, i.q.r.) 3 (2–3) versus 3 (3–5) days (P < 0·001). A 2-day hospital stay was achieved in 44 and 8 per cent of patients respectively (P < 0·001). Patients in the ERP had a shorter time to recovery of bowel function: median (i.q.r.) 1 (1–2) versus 2 (2–3) days (P < 0·001). Thirty-day complication rates were similar (32 per cent ERP, 27 per cent FTP; P = 0·570). Readmissions within 30 days were more common with ERP, but the difference was not statistically significant (10 versus 5 patients; P = 0·170). Total hospital stay for those readmitted was shorter in the ERP group (18 versus 23 days). Conclusion ERP decreased the length of hospital stay after minimally invasive colorectal surgery. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Background Previous studies suggest that intraoperative anesthetic care may influence postoperative pain and recovery from surgery. The authors tested the hypothesis that the addition of intrathecal analgesia to general anesthesia would improve long-term functional status and decrease pain in patients undergoing radical retropubic prostatectomy. Methods One hundred patients received either general anesthesia supplemented with intravenous fentanyl or general anesthesia preceded by intrathecal administration of bupivacaine (15 mg), clonidine (75 microg), and morphine (0.2 mg). Patients and providers were masked to treatment assignment. All patients received multimodal pain management postoperatively. Primary outcomes included pain and functional status over the first 12 postoperative weeks. Results Patients receiving intrathecal analgesia required more intravenous fluids and vasopressors intraoperatively. Pain was well controlled throughout the study (mean numerical pain scores < 3 in both groups at all times studied). Intrathecal analgesia decreased pain and supplemental intravenous morphine use over the first postoperative day but increased the frequency of pruritus. Pain and functional status after discharge from the hospital did not differ between groups. Intrathecal analgesia significantly decreased the duration of hospital stay (from 2.8 +/- 2.0 to 2.1 +/- 0.5 days; P < 0.01) as a result of five patients in the control group who stayed in the hospital more than 3 days. Conclusions The benefits of improved immediate analgesia and decreased morphine requirements resulting from intrathecal analgesia must be weighed against factors such as pruritus, increased intraoperative requirement for fluids and vasopressors, and resources needed to implement this modality. Further studies are needed to determine the significance of the decrease in duration of hospital stay.

Background The goal of this project was to study the frequency and natural history of perioperative lower extremity neuropathies. Methods A prospective evaluation of lower extremity neuropathies in 991 adult patients undergoing general anesthetics and surgical procedures while positioned in lithotomy was performed. Patients were assessed with use of a standard questionnaire and neurologic examination before surgery, daily during hospital stay in the first week after surgery, and by phone if discharged before 1 postoperative week. Patients in whom lower extremity neuropathies developed were observed for 6 months. Results Lower extremity neuropathies developed in 15 patients (1.5%; 95% confidence interval, 0.8-2.5%). Unilateral or bilateral nerves were affected in patients as follows: obturator (five patients), lateral femoral cutaneous (four patients), sciatic (three patients), and peroneal (three patients). Paresthesia occurred in 14 of 15 patients, and 4 patients had burning or aching pain. No patient had weakness. Symptoms were noted within 4 h of completion of the anesthetic in all 15 patients. These symptoms resolved within 6 months in 14 of 15 patients. Prolonged positioning in a lithotomy position, especially for more than 2 h, was a major risk factor for this complication (P = 0.006). Conclusions In this surgical population, lower extremity neuropathies were infrequent complications that were noted very soon after surgery and anesthesia. None resulted in prolonged disability. The longer patients were positioned in lithotomy positions, the greater the chance of development of a neuropathy. These findings suggest that a reduction of duration of time in lithotomy positions may reduce the risk of lower extremity neuropathies.