PDX_RN

my point is actually really simple and can be summarized in three sentences. 1: deviations from standard clinical practice guidelines during in-hospital arrest are a very common occurrence - to simply say "not me"; "not my team"; "not my institution" is too live outside reality. 2: a major responsibility, perhaps the major, responsibility of the code leader is to make sure that the algorithms are being carried out correctly and optimally. 3: there are tools available, including the aha algorithm cards, which can be helpful to in some situations to assist the code leader in helping keep everything running smoothly. i think if anyone who has been to very many codes has seen some that frankly were not run well. the evidence demonstrates that happens way too often. and like 'em or not, when we deviate from the guidelines, we are not giving are patients the best chance for survival.

Ask yourself if you would be more frightened by having someone double check a drug dosage that they were not 150% sure of versus them relying solely on their memory in a stressful situation that for some of the readers of this forum is likely not an everyday, or even every month situation and likely giving your loved one the wrong medication? The fact is, people make mistakes in codes quite frequently. This is actually something that has been studied extensively and we know that patients get the wrong med, or the wrong dose, at the wrong time, around 10-30% of the time. Deviations from practice guidelines happen a lot. Many readers of this forum will read that and think they couldn't possibly be responsible for a med error, but it happens are patient outcomes not doubt suffer for it. I was not describing a situation where the code leader is clueless about what to do, and stares blindly at a algorithm, card like it was the first time they've seen one. But get serious, you got 2 minutes of compressions before the next action. Why not take a deep breath; look at your card; double check that dosage; make sure you aren't forgetting anything; ask your team members if they have any ideas? I don't think it adds anything to the discussion to scoff at someone who is humble enough to make use of an available tool, to ensure that they are adhering the best available scientific data as they attempt a resuscitation. Quick: what's the max dose of lidocaine you should give a 79 kg man in refractory v-fib? If you think you might have even a shadow of a doubt what the answer is in the heat of a code with the pressure cooker on high, why not make sure you know where your little flip book is? Because if you get it wrong, it will likely be by a factor of 10. That can't be good.

I think new hires to my ICU also orient for a period of time prior to taking an ACLS class. That is definitely the case on the step-down unit where I started. I think either way is fine. The point is that no new grad should be responding to codes as a code leader while they are still on orientation. And when you do, you shouldn't be alone. It's a team activity. Unfortunately, you probably won't have the same outcomes in terms of survival rates during a real code.

The current emphasis in ACLS instruction is to teach people to use their tools. At my hospital, we keep the alogorithm cards on the code cart. We are expected to refer to them in an actual code. Trying to rely solely on memory is a recipe for error. I doubt you will feel confident in taking on this battle, but I think that if your nurse educator is actually expecting you memorizing the algorithms and run codes without the benefit of memory aides such as the AHA cards she is behind the times.

If anyone can find a study that demonstrated improved patient outcomes based on price of their nurse's stethoscope I'd love to see it. I'm pretty well convinced that a $200 stethoscope is more often than not a fashion accessory. Here is a study that suggests they don't make much a difference: Am Heart J. 2006 Jul;152(1):85.e1-7. Effect of teaching and type of stethoscope on cardiac auscultatory performance. Iversen K, Søgaard Teisner A, Dalsgaard M, Greibe R, Timm HB, Skovgaard LT, Hróbjartsson A, Copenhagen O, Copenhagen S, Copenhagen K. Clinic of Cardiology, Rigshospitalet, Copenhagen Ø, Denmark. [email protected] BACKGROUND: Auscultation of the heart is a routine procedure. It is not known whether auscultatory skills can be improved by teaching or with the use of an advanced stethoscope. METHODS: This study was a randomized trial with a 2 x 2 factorial design. Seventy-two house officers were randomized to a simple or an advanced stethoscope and to a 4-hour course in auscultation or no course. The doctors auscultated 20 patients' hearts and categorized findings as normal or as one or more of 5 categories of heart diseases. Patients were selected such that 16 had a known heart disease as well as a corresponding murmur and 4 had no heart disease or murmur. Auscultatory performance was assessed as concordance with echocardiographic findings and interobserver variation. RESULTS: Doctors using the advanced stethoscope diagnosed 35% of the patients correctly, as compared with doctors using the simple stethoscope who did 33% of the patients (P = .27). Similarly, 34% of the patients were diagnosed correctly by doctors who had received teaching as compared with 33% of those who were by doctors who had received no teaching (P = .41). The kappa values were higher for doctors who had received teaching for aortic stenosis (0.43 vs 0.28, P = .004) and ventricular septum defect (0.07 vs 0.01, P = .003). There was no difference between groups for any other single murmur or for the detection of murmurs as such. CONCLUSION: Heart auscultation findings were in poor accordance with echocardiographic findings and had high interobserver variation. Neither outcome improved to any important extent with the subjects' use of an advanced stethoscope or attending of a course in heart auscultation.

Dale Dubin's book (in addition to his website) is really great. Rapid Interpretation of EKGs. I have read it several times.

According to Bard, the power picc is indicated for monitoring CVP (http://www.bardaccess.com/powerpicc//faq.php). I think it is the Groshong PICC that can potentially dampen the CVP waveform. However, perhaps an even more important consideration is whether or not the CVP is a reliable indicator of fluid status. Here is a reference to a recent review article that debates the reliabilty of CVP monitoring for assessing fluid status. Marik, P. E., Baram, M., & Vahid, B. (2008). Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest, 134(1), 172-178. doi: 10.1378/chest.07-2331. http://chestjournal.chestpubs.org/content/134/1/172.full

hello, i am developing a reading list to hand out to new hires and nursing students who are new to critical care to provide a framework/historical background/basis of evidence for many of our common practices. has anyone else here tried to create something like this? of course a reading is inherently controversial in terms of inclusions and omissions and this list is not intended to be perfect or comprehensive, but rather to help get someone new to critical care started off in the right direction of having an evidence based nursing practice. any suggestions for other articles or resources to include in this list would be appreciated. the list (in progress) follows: thanks in advance for your comments. glucose control in the icu nice-sugar study investigators, finfer s, chittock dr, su sy, blair d, foster d, dhingra v, bellomo r, cook d, dodek p, henderson wr, hébert pc, heritier s, heyland dk,mcarthur c, mcdonald e, mitchell i, myburgh ja, norton r, potter j, robinson bg, ronco jj. (2009). intensive versus conventional glucose control in critically ill patients. n engl j med. 26;360(13):1283-97. van den berghe, g, et al. (2001). intensive insulin therapy in critically ill patients. n. engl. j. med. 345:1359-1367. therapeutic hypothermia bernard sa, gray tw, buist md, jones bm, silvester w, gutteridge g, smith k. (2002). treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia n engl j med 346:557 hypothermia after cardiac arrest study group. (2002). mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. n engl j med. 21;346(8):549-56. http://content.nejm.org/cgi/content/full/346/8/549 sepsis (early goal directed therapy) dellinger rp, levy mm, carlet jm, et. al. (2008). surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008 [published correction appears in crit care med 2008; 36:1394-1396]. crit care med; 36:296-327. rivers, e, et al. (2001. early goal-directed therapy in the treatment of severe sepsis and septic shock. n. engl. j. med. 345:1368-1377. ards - lung protective ventilation the acute respiratory distress syndrome network. (2000). ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. n engl j med. 342: 1301-1308 bernard gr, artigas a, brigham kl, et al. (1994) the american european consensus conference on ards: definitions mechanisms, relevant outcomes and clinical trial coordination, am j respir crit care med. 149:818-24. eichacker pq, gerstenberger ep, banks sm, et al. (2002). meta-analysis of ali and ards trials testing low tidal volumes. am j respir crit care med; 166:1510-4. best practice bundles girard t, kress j, fuchs b, et al. (2008). efficacy and safety of paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awake and breathing controlled trial): a randomized controlled trial. lancet; 371:126-34. tablan, o. c., anderson, l. j., besser, r., bridges, c., & hajjeh, r. (2004). guidelines for preventing health-care--associated pneumonia, 2003: recommendations of cdc and the healthcare infection control practices advisory committee. mmwr. recommendations and reports: morbidity and mortality weekly report. recommendations and reports / centers for disease control, 53(rr-3), 1-36. http://www.cdc.gov/ncidod/dhqp/guidelines.html - a collection of guidelines for the prevention of health care associated infections. miscellaneous connors af, speroff t, dawson nv, et al. the effectiveness of right heart catheterization in the initial care of critically ill patients. jama 1996;276:889-897. gawande, a. the checklist: if something so simple can transform intensive care, what else can it do? the new yorker. december 10, 2007. http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande useful websites www.survivingsepsis.org/pages/default.aspx www.learnicu.org www.pacep.org www.icudelirium.org www.ardsnet.org

You could start by looking here: http://www.aana.com/

Thanks for the encouragement. I do plan to apply this year, but am still wondering how many schools I should apply to in order to have a reasonable chance of getting into at least one of them. It is hard to be at all confident when many schools are reporting 5 applicants for each seat.

I just realized I left out a crucial part of my prior post. Experience: I have been an RN for a little over two years with half of it spent on a medical ICU in a large urban, level I trauma center.

Any advice about the application and selection process for admission to a CRNA program would be greatly appreciated. I am scheduled to take the GRE next month, and am taking a CCRN prep class this summer and plan to take the exam shortly after the test. I recently completed a Rn-to-BSN program with a 3.968 GPA. I also have a 4.0 from my ADN degree and all pre-requisits for that. I did a senior pracitum with a CRNA for my last BSN clinical which was about 70 hours and was very hands on. I have also served on a couple commitees at my hospital of employment. Assuming I pass the CCRN exam and score reasonably well on the GRE what do people think of my chances of getting in now, versus waiting another year or two before applying? I feel a little intimidated knowing that my competition will probably have much more experience, yet, the longer I wait, the older my A&P and chemistry classes will be. I'd rather not be in the position of feeling like I should retake those classes to be competitive. I plan to apply to at least four or five programs this fall and winter and see what happens? What do people think? Should I look at more programs? Wait? Go for it now? Thanks in advance!