Summer 2016 Clinical Update We are pleased to offer this archive of our award-winning newsletter Clinical Update. There are 75 issues in this document. Each issue has a feature article, summaries of articles in the nursing literature, and Web sites of interest. By downloading and using this archive, you agree that older medical articles may no longer describe appropriate practice. The issues are organized in date order from most recent to oldest. The following pages offer tips on how to navigate the issues and search the archive in Adobe Acrobat Reader. In 2006, we were honored to receive the Will Solimine Award of Excellence in Medical Writing from the American Medical Writers Association, New England Chapter. Issues that received the most positive response over the years include: • Nurses Removing Chest Tubes, a discussion of state boards of nursing’s approaches to this extended practice for registered nurses • Medical Adhesive Safety, a review of guidelines published by the Wound, Ostomy and Continence Nurses Society, complete with original tables identifying characteristics of each type of medical tape and how tape components contribute to medical adhesive- related skin injury (MARSI) • Autotransfusion for Jehovah’s Witness Patients, an explanation of the Biblical origins of the reasons for refusing blood transfusion and how continuous autotransfusion may offer an option that is acceptable to members of the faith • Air Transport for Patients with Chest Tubes and Pneumothorax and Chest Drainage and Hyperbaric Medicine, in which each issue provides a thorough analysis of how pressure changes with altitude and with increased atmospheric pressure affect chest drainage and untreated pneumothorax • Age Appropriate Competencies: Caring for Children that describes developmental stages and strategies to deal with a child’s fears at each stage Creative Commons License This work is licensed under a Creative Author: Patricia Carroll RN-BC, RRT, MS Commons Attribution-NonCommercial- ShareAlike 4.0 International License. Navigating the Clinical Update Library in Adobe Acrobat Reader When you open the file in Acrobat Reader, you can click on the page icon in the top of the left margin to see thumbnails of each page in the document. The margin shows a thumbnail of each page, and the top of the margin identifies the view “Page Thumbnails” To close the thumbnail view, click on the X next to the title bar (arrow) Another view is Bookmarks. To access this view, click on the bookmark icon (circled) This provides a list of the main article in each newsletter. You can click on any title and go straight to that page. As with Page Thumbnails, the title bar in the left margin says “Bookmarks” and you can close this view by clicking the X in the title bar You can also search the library with the Acrobat Reader built-in search tool. Click on Edit > Find OR Ctrl + F (control key in the lower left of your keyboard and the F key at the same time) This will bring up the Find box: Type in your keyword and click on Next. Acrobat Reader will then start searching the document. The first instance of the keyword will be shown, with the word highlighted. Each time you click Next, the following instance of the word will be highlighted until you have reached the end of the document. Then, the Find function will start from the beginning again. You can also go backward by clicking Previous at the bottom of the search box. Summer 2016 Clinical Update Research Review 2015 – Part Two In this issue of Clinical Update, we continue with the chest wall. our review of the literature published on chest drainage The sixth intercostal space (ICS) was the one most in 2015. The previous issue covered trauma, cardiac commonly identified by all methods, with a range of the surgery, lung resection, and pleural effusion. You can 3rd to 8th ICS. The 5th ICS or above was marked in only read that issue here. In this issue, we will cover chest 16/96 attempts (17%) regardless of guideline followed. tube insertion, general chest tube management, and The trauma guidelines marks completely avoided the digital drains. long thoracic nerve and 96% of the nerve branches.3 Chest Tube Insertion The same researchers then designed a study using A number of authors looked at chest tube insertion 31 volunteers in their 20s (62 sides for tube placement) in 2015. While the procedure is generally safe in the to compare locations following the same guidelines.4 hands of experienced practitioners, surveys and audits The original article provides detailed explanations of continue to reveal concerns related to lack of experi- the different methods. The authors used ultrasound to ence or knowledge about managing pleural conditions.1 confirm locations. Physician groups in the UK are carefully examining how The site selected was significantly more likely to physicians are trained; one author notes true procedural overlie the sixth intercostal space or below in women competence is not only the technical proficiency but compared with male volunteers, as was noted in the the clinical knowledge to determine when a procedure cadaver study. Individual methods that relied on the is and is not indicated.1 Furthermore, what happens to nipple line also resulted in significantly lower marks in skills over time? Once training is over, how are skills women volunteers. There was no difference between maintained? Should chest tube insertion be limited to a right and left sides of the chest. Of note, the degree small group of expert practitioners, perhaps through a of arm abduction changed the relationship of the skin pleural consultation service, or should all hospital-based marking to underlying rib margins. Ultrasonography clinicians be required to maintain the competency? can be used to confirm the site; however, results are One expert group conducted a survey of 66 internal affected by body habitus and operator experience.4 medicine trainees, asking them to choose the location Kentucky researchers did a retrospective review to for safe tube insertion in a man with large symptom- evaluate the location of the distal tip of the tube after atic pneumothorax and mark it on a photograph. Two insertion and whether that location affected tube func- experts were also asked to mark the “triangle of safety” tion in 291 trauma patients who had CT scans after on the same picture. Forty of the 66 physicians marked chest tube insertion in the emergency department.5 The a site within the safety triangle; 20/26 of the incorrect most common placement was in the 6th ICS (36%), with sites were too low.2 26% in the 5th ICS; 39% were directed to a posterior UK researchers identified chest tube placement location within the chest, and 34% were in a fissure. locations on cadavers with a mean age of 84 years.3 One tube was placed below the diaphragm, and two They compared the British Thoracic Society, Advanced within the axillary soft tissue. Trauma Life Support and European Trauma Course The detailed statistical analysis found the tubes guidelines for identifying the fifth intercostal space to “worked” regardless of how the clinician directed the avoid subdiaphragmatic tube placement. Guidelines distal end, even if it ended up in a fissure. Like direction, were developed because the traditional palpation of ICS was not associated with the need for secondary the intercostal spaces is challenging in obese or mus- interventions (second tube, VATS, thoracotomy, or cular patients and those with trauma. The authors also interventional radiology drainage) unless the tube was considered avoiding damage to peripheral nerves of too low. the chest wall. Experienced clinicians marked insertion Canadian pediatric emergency specialists devel- sites, following guidelines. A senior anatomy professor oped a day-long procedural training course with “task evaluated anatomical accuracy following dissection of trainers” that simulated the pediatric chest for practice.6 Learners were expected to complete Web-based mod- Clinical Update is edited by Patricia Carroll, MS, RN-BC, CEN, RRT, and supported by an educational grant from Atrium Medical Corporation. Continued on page 3 Clinical Update for the Professional Nurse Summer 2016 In the Literature Sepsis: What’s in a Name? Owls and Larks and the Effect on Shift Work Balance The current issue of Critical Care Medicine offers two A fascinating article in the Journal of Nursing Scholarship must-read editorials about sepsis. The new definition, examines how a nurse’s chronotype (his or her person- “life-threatening organ dysfunction caused by a dys- al circadian rhythm), the shift schedule, and the nature regulated host response to infection” published in JAMA of work on each shift affect both job-related and general earlier this year. One author questions the requirement well-being. Researchers looked at three settings: an of infection as the trigger; what about pancreatitis, heat acute care hospital, a maternity hospital, and an SNF shock, ischemia-reperfusion injury and endotoxemia, and defined operational characteristics such as occu- that result in a similar clinical presentation through the pational hierarchy, autonomy, skill utilization, patient same biologic pathways? He notes the advance in profile, health conditions, nature of common services, the focus on organ dysfunction and the more generic intrinsic rewards, and differences in work demand by description of a dysregulated response rather than shift in each of the practice areas. They then surveyed characterizing the response as pro-inflammatory, for nurses on each shift in each practice area, looking at example. His editorial is a valuable analysis of how we chronotype, negative affectivity, job satisfaction and come to these definitions and how diagnostic criteria general mental health. This research provides impor- and therapeutic stratification flow from them. The other tant data for nurse managers who want to enhance their explores the long-term consequences faced by sepsis staff’s adaptability to shift work.