Neuro Patients have Higher Rates of CAUTIs?

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I decided to report on this article since it incorporates a bit of our NRS420 topic of sepsis (prevention) and current topic of neuro. As we know, preventing HAI is paramount in the hospital setting, and the neuro ICU seems to be no exception.

According to the CDC’s National Healthcare Safety Network which tracks national infection statistics, 30% of infections are UTIs and 75% of UTIs acquired from the hospital occur from catherization (CDC, 2015). Since 15%-20% of hospitalized patients receive catherization, this can amount to large numbers.

Due to the possible delicate nature/acuity of neuro-spine conditions, these patients are especially prone to longer ICU stays, increased needs for invasive devices (central lines, ventilators), limited mobility and urine retention. Reduction of CAUTIs (catheter-associated urinary tract infections) is especially difficult in the NSICU due to the neuro-spine patient’s debility which generally requires long-term foley-catheterization and longer stays. Topping the list of neuro conditions seen in neuro ICUs is the incidence of acute ischemic stroke, which averages a hospital stay of 5-14 days average (George et al,2013). Considering that occurrence of CAUTIs peaks at 12 days (plus) puts these particular stroke patients at high risk if catheterized with a foley-catheter (George et al,2013).

This article was written about a study done at one hospital’s neuro-spine ICU unit, as it represented that hospital’s unit with the greatest number of HAI/UTI. This is not unusual I surprisingly found, as neuro-spine ICUs have been found to nationally represent the unit with the most incidences of CAUTI, (Edwards, 2008).

Great concern has arisen for the neuro-spine patient population; the hospital cited in the study decided to utilize their in-house Infection Prevention team to assess and advise the neuro-spine ICU staff. Their conclusion was to implement a plan where either nursing leadership or Infection Prevention staff performed separate rounding to identify at-risk patients. Assessments and recommendations were made on the following gathered criteria: catheter presence, indication and possibility of removal. Their NSICU now includes an increased mindfulness when evaluating catheter necessity, care, and removal.

It is eye-opening that neuro-spine ICU units have been identified as the top needs-to-be-watched unit concerning catheter associated UTIs. I found no less than 5 studies about CAUTI concern conducted in neuro units during my research regarding infection. I originally began research on infection (general) and neuro topics, but found this one topping the list of searches…and it turned out to be enlightening and has served to increase my overall vigilance during my clinical rotations.

 

REFERENCES:

Center for Disease Control (2015, October 16). Catheter-associated Urinary Tract Infections (CAUTI). Retrieved November 10, 2015, fromhttp://www.cdc.gov/HAI/ca_uti/uti.html

Edwards JR, Peterson KD, Andrus ML, Dudeck MA, Pollock DA, Horan TC (2008). Center for Disease Control and Healthcare safety network (NHSN) report, data summary for 2006 through 2007. Retrieved November 10, 2015, from http://www.cdc.gov/nhsn/NationalAm J Infect Control. 2009 Jun;37(5):425.

George, A., Boehme, A., Siegler, J., Monlezun, D., Fowler, B., Shaban, A., Martin-Schild, S. (2013). Hospital-Acquired Infection Underlies Poor Functional Outcome in Patients with Prolonged Length of Stay. Am J Infect Control; 36:609-26.

Schelling, K., Palamone, J., Thomas, K., Naidech, A., Silkaitis, C., Henry, J., Zembower, T. (2015). Reducing catheter-associated urinary tract infections in a neuro–spine intensive care unit. American Journal of Infection Control, 83(1), 892-894.

 

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New Neuro Intervention: RAPID Automated Patient Selection for Re-perfusion Therapy

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When a person presents with an ischemic stroke in the ED, often tPA can’t be given due to many factors. One reason is that, the patient may present with an ischemic stroke but the last time the patient is well is unknown, therefore excluding them from receiving the tPA therapy. However, recent research using automated image analysis software such as RAPID has changed this approach. Research has shown that the use of RAPID extends the tPA treatment window as it shows a more accurate picture of the brain’s perfusion status. RAPID allows the physicians to assess whether the patient is a candidate for tPA therapy not based on when the patient was last seen well, but actually based on the patient’s cerebral perfusion status. In other words, the treatment depends on the amount of tissue infarct and deficit, not when the the patient was last seen well.

References:

http://stroke.ahajournals.org/content/42/6/1608.full

 

345G1 2015-11-09 21:57:20

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Chapter 9

“5 million alcohol abusers have children under eighteen living with them” (Sternheimer, 219). When using the video of Miley Cyrus, for example and saying that kids are going to copy her behavior. I say it is a stupid concept, I don’t nor have I ever copied the dumb things that celebrates or even loved ones do. Its back to the old saying,”if so and so jumped off a bridge would you do it”. This whole role model thing is really stupid when you don’t even know Miley Cyrus personally, why is she effecting the choices you make>?

In Sternheimer she discusses the only reason that children are not smoking is because their parents are not (p. 221). Even though I do not agree on making someone you have never met your role model. I do agree that children copy their parents.

The quote on page 227 is very interesting,”Movie smoking may be a last-ditch effort of the tobacco industry to advertise through product placement…”It makes sense its the last way for them to advertise, so of course their going to push themselves into motion pictures.

Talking about alcohol, the older generation keeps surprising us in this book. Sternheimer talks about 55-59 year olds binge drinking? Heavy drinking is drinking more than five times a month? She is right when she says no one is taught how to safely drink and this an issue.

People so often joke about eating or smoking or drinking the wrong thing. Just today in class, a few classmates sitting next to me were talking about how “everything gives you cancer” and as a classmate drank a Monster he laughed and said this probably has cancer. AND we know for a fact now that meat has cancer causing agents in it (thank you World Health Organization)..  I TRIED TO PUT THE LINK BUT IT AINT WORKING. So, why are we so quick to throw shade at cigarettes and alcohol BUT NOT MEAT!?

I also am very confused about this new concept of over dosing on over the counters to become high, i think people nowadays are bored, maybe we should give them more homework.

passions

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haven’t been in the mood to do anything recently. need to rediscover myself.

Newer Intervention in Care of Neuro Patients

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I actually wrote my EBP on the stroke alert policy and I found so many good articles about the management of stroke. One of the articles was quite interesting since it talked about a drug that is under research right now. According to that article, tPA has the ability to modulate blood vessel tone and to increase blood-brain barrier permeability (Freeman, 2014). The non-fibrinolytic action on the blood-brain barrier may be related to the ability of tPA to induce intra-cranial hemorrhage and cerebral edema (Freeman, 2014). The tPA is the only approved thrombolytic agent for patient with ischemic stroke. It has many limitations and inclusion criteria, like strict time constraints of 3 to 4.5 hours since the onset of symptoms, low risk of bleeding, have a measurable persistent neurological deficit, negative non-contrast head CT scan, serum glucose between 50–400 mg/dL, platelet count above 100,000/mcL, and INR less than 1.7, etc. (Berry et al., 2015).

The new drug, desmoteplase, is not approved by FDA yet, but is under clinical development now. It is considered to be a safer option compared to tPA, since it does not induce plasmin-dependent opening of a blood-brain barrier and has less risk of inducing intra-cerebral hemorrhage (Freeman et al., 2014).

Another article that I actually have not used for my paper talks about the economical impact of tPA. According to its authors, the use of tPA accounts for a cost-saving of $3454 per treated patient over a six-year period (Kazley, 2013). This study was done in South Carolina. The article estimates that increasing the current use of tPA from 3% to 20% over the five years will potentially increase the cost-savings to $16,615,723 (Kazley, 2013). Calculating the cost-saving costs, the researchers included daily rehabilitation cost, daily home health cost, etc., of patients treated with tPA and those who were not treated. I liked the idea of increasing the tPA to 20% and improved economic impact. However, tPA has so many exclusion and inclusion criteria, and thus many limitations. So this goal might be very hard to achieve with tPA. Desmoteplase, on the other hand is so much safer and has fewer limitations, so it could be used in many more cases to improve patients outcomes and achieve their higher cost-saving economical impact.

References

Berry, K., Al-Zubidi, N., & Seifi, A. (2015). Should serum sodium level be part of stroke protocol prior to tPA administration? Journal of the Neurological Sciences, 357(1), 317-318. http://dx.doi.org/10.1016/j.jns.2015.07.035

Freeman, R., Niego, B., Croucher, D., Pedersen, L., & Medcalf, R. (2014). tPA, but not desmoteplase, induces plasmin-dependent opening of a blood-brain barrier model under normoxic and ischemic conditions. Brain Research, 1565 (1), 63-73. doi: 10.1016/j.brainres.2014.03.027

Kazley, A., Simpson, K., Simpson, A., Jaunch, E., & Adams, R. (2013). Optimizing the economic impact of rtPA use in a stroke belt state: The case of South Carolina. American Health & Drug Benefits, 6(4), 155-162.

 

 

Thoracic Outlet Syndrome

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Hi everyone, this is Breehan!

 

For this neuro-related blog, I wanted to focus on an usual neurological disorder known as Thoracic Outlet Syndrome (TOS), explained well in a 2015 article from the journal Vascular Medicine by well-known TOS surgeon Dr. Ying Wei Lum.

 

TOS is when the brachial plexus and/or the subclavian veins and arteries that are proximal to the plexus, near the collarbone, are compressed by one or more structures that make up the thoracic outlet.

 

The compression is usually caused by a “cervical rib,” an elongated transverse process that generally comes from C7. The extra rib can fuse with the first rib, which then causes compression. The scalenes and subclavius muscle can become spastic hypertrophied, and fibrous, further contributing to the compression. In addition, the pec minor, levator scapulae, and rhomboid can develop spasms and fibrotic tissue.

 

TOS can be caused by a past history of acute trauma or chronic repetitive movement.

 

The reason I am interested in this particular disorder is because I am afflicted with TOS. I have the “extra rib” coming off of C7 on my right side. I present with the classic symptoms of TOS—Constant severe pain in my neck, clavicle, cervicogenic migraines from the tight scalenes, and cervical dystonia from the spasms. The vascular symptoms in my right arm due to the compression of the subclavian artery cause my right radial pulse to completely disappear when I use my right arm and it often feels cold, fatigued and achy, like any patient with intermittent claudication in their legs. Mine just happens to be in my arm.

 

According to Lum, I am at risk for clots and aneurysms in my arm, which requires me to avoid using my right arm too extensively and watch for symptoms of one. If I were to get a clot, I would need emergency treatment, thrombolysis and need anticoagulants until I am able to have surgery, which I am going to have next month at UCLA with a vascular surgeon.

 

I followed Lum’s recommendations for my treatment, starting with physical therapy to correct my hunched over posture, which worsened my TOS pain and Botox injections to help relax the spastic muscles. When these conservative therapies failed and the TOS pain and dysfunction worsened, the neurologist I was seeing recommended surgery.

 

The decompression surgery I will have next month at UCLA is the same one Dr. Lum performs at Johns Hopkins. The surgeon resects the “extra” rib plus the first rib, both of which are causing the compression. He then partially removes some of the hypertrophied spastic scalene muscles. This should enlarge the thoracic outlet and eliminate most of my symptoms.

Lum notes that there is no real cure for TOS, only treatments to put it into a remission of sorts. While my vascular symptoms will be gone, the neurogenic ones causing the severe pain may or may not return.

 

There are two reasons I wanted to discuss TOS today. First of all, it is rare but not entirely unheard of and it is important that nurses be aware that it is possible to have intermittent claudication as well as clots and aneurysms in an upper extremity. The patients with vascular emergencies will be seen in critical care for these reasons but there is another reason TOS patients seek out the emergency room: Severe, unremitting pain.

 

TOS is by its nature very hard to treat. It affects me every single hour of every day as I await my surgery. The pain is deep, achy and severe. It is similar to having one of those horrible “charley horse” muscle spasms you may experience in your legs that goes away. Except my pain sticks with me and almost any activity triggers it. Even lying in bed on my affected side causes severe neck and head pain.

 

Some TOS patients present to the ED looking for help with their pain. Because they “don’t look sick,” TOS tends to affect young, healthy people, these patients are often not taken seriously or worse, treated as drug seeking.

 

But these are people experiencing very hard to treat neuropathy and must be treated as such and as patient advocates we must believe them when they say their pain is a 10/10. TOS is hard enough to live with as it is, and we nurses can either choose to make their day worse when they come seeking help, or we can be a bright spot while they deal with this very difficult diagnosis.

 

Lum, Y. (2015). Thoracic Outlet Syndrome. Vascular Medicine, 20(5), 493-495. doi: 10.1177/1358863X15598391

 

 

 

 

 

 

 

 

thoracic-outlet-syndrome

WSN!

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This weekend I was able to present my research project in the poster session at WSN in Sacramento, CA.  I had an awesome time meeting other students and professors from all over the place.

Here are a few pictures from the weekend.L1030298L1030304 L1030302 L1030305

Week 11 Readings

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Sorry for the late post! I think my midterm season seems to have come a couple weeks after everyone else’s.

tumblr_inline_ml53cwSSGx1qheoy4(Sherlock anyone?)

Anyways, how did everyone’s anti-ad end up? I really liked the assignment and I think if I were teaching media literacy I would definitely use it in a classroom (especially with teenagers!).

On the topic of readings, I (once again) found this week’s readings interesting. However, I actually found more interest in Sterheimer’s chapter than the Harris and Bargh report (article? research?). I have always found the connection between media and eating disorders and obesity really fascinating so I was very intrigued by this section of the book. The biggest takeaway I took was that  there are different responses to media depending on the person consuming it (p.204). I think this is a really important point to note when looking at any “affects” of media, from violence to sexuality and now health. I did find Sterheimer’s history of “fasting girls” and the changes in societal perceptions about weight really interesting since I had never heard about most of it. I do agree with her statement that media can contribute to body dissatisfaction but not necessarily eating disorders. I know many of us can feel, after reading the September issue of Vogue for example, not too comfortable in our own bodies. I’m trying to think of ways that we could combat this, but I can’t think of anything that is beyond the individual’s responsibility (i.e. putting down the magazine once they feel uncomfortable, searching for body-positive types of media). I wish there was some sort of anti-media magazine that had realistic and unairbrushed models (men AND women!). I know American Eagle has taken to not photoshopping models for their lingerie line, but I think there should be more than just advertisements that take this approach. Any ideas?

The next reading was the Harris and Bargh study about food preferences and the influence of television on eating. The point they seemed to repeat time and time again (and even tested) was that perceived taste is the most important determining  factor for healthy and unhealthy food preferences. How the heck do we fight something that is inherent? Genetic even?? I know they gave some solutions like PSAs, parent-child communication, and reducing exposure to unhealthy message on TV. However, if we are built with a taste preference, how do we change it? I did find it interesting that their study found that the relationship between early TV viewing and unhealthy eating continues into early adulthood (p. 14). I wonder if they did a longer study if the same findings would continue through adulthood and on-wards? Do any of you feel like watching TV when you are younger caused you eat unhealthy? I will say that I think I fell privy to the “free toy” thing, especially if it was for a show or movie or something that I really liked. I mean, who doesn’t want a Hello Kitty watch with their kid’s meal??

November 9th

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Sternheimer Ch. 8 Media Health Hazards

This chapter was more upsetting rather than surprising. Learning about obesity and eating disorders is never a cheery subject, however it is a very important one. This chapter started out talking about the “inactivity and overeating with ads of junk food creating a child obesity machine.” The media creates many things along with this obesity machine such as impossible standards of beauty, low self-esteem, social rejections, overall body dissatisfaction, damaging habits and so on. The chapter explains that the link between obesity and the media/TV is weaker than we are told. (Shocking something is dramatized to the public yet again) Adults are more likely to be overweight then kids and minority children are more likely to be overweight than white children. Pointing fingers and blaming the media however will not solve these health and social issues it just causes further tension and frustration. As I have always said the media isn’t going anywhere education from others is really the only option. You can’t hide everything away from the youth. When the article talked about eating disorders and how rare yet serious they are I thought it was interesting that several countries had created a minimum BMI for models that they had to follow. The U.S cannot officially created a minimum BMI but individual companies can decide what models they want based off a relative BMI. I also thought it was interesting that TV doesn’t really affect eating disorders as it does for the obesity epidemic. I think it is important to take note that they issues aren’t just for women and children. Men and adults everywhere deal with these issues and many people are unaware of the fact. They think eating disorders is a “women thing”.

PDF article The Relationship between TV viewing and unhealthy eating implications

This article at the start bothered me a bit because right away is started with the blame game, which I cannot stand because that won’t accomplish much for this issue. But then the article went into various statistics and solutions that were different than the reading in the book. The fact that “98% of advertised foods are of low nutrients” bothers me incredibly but at the same time it is also not that surprising. The three solution that this article had were 1-messages to show children how important heathy foods are, 2- parent child communication and media education, and 3- reductions in overall exposure. These are rather good solutions that need to be easily broken apart so that adults can not only gain this knowledge but pass it on to the youth. If the parents struggle themselves then there needs to be options for children to learn about healthy eating on their own. No part of this issue is easy to overcome but it can be overcome one step at a time with balance, interaction, and doing more than just figuring out who should take all the blame.