Capstone Project: The effectiveness of Dexmedetomidine on respiratory adverse
events, overall use of narcotics, and pain levels in perioperative patients with
obstructive sleep apnea: A systematic review
DNP Student: Cresilda Newsom (Recipient of 2014 Best Capstone Project Award)
Abstract:
Objective: The aim of this systematic review was to evaluate whether the use of
Dexmedetomidine (Dex) decreases respiratory adverse events, overall use of narcotics,
and pain levels in perioperative patients with obstructive sleep apnea (OSA).
Inclusion criteria: We included studies that measured the following outcomes: amount
of narcotic pain medication use, patient level of pain, and adverse respiratory events
which may include rates of respiratory depression and rates of oxygen desaturations.
The participants were adult surgical patients (ages 18 years and older) who are
diagnosed with OSA or who are at risk for OSA as determined utilizing the STOP BANG
questionnaire and who had surgery in the past 48 hours.
Search strategy: We conducted an exhaustive, comprehensive search of the published
and grey literature using a three-phase approach with publication limited to years 19992014 and those written only in English. We searched CINAHL and MEDLINE to identify
all key words. Subsequently, we used a structured Boolean search of all relevant
bibliographic and grey literature databases. Finally, we hand-searched the reference
lists of included and other highly relevant, recent articles. Two independent investigators
reviewed the search results to make the decision to retrieve studies for critical appraisal.
Methodological quality: Two independent reviewers appraised all reports using
standardized critical appraisal tools of the Joanna Briggs Institute, specific for the
particular research design.
Results: The search netted 1762 unique reports; 117 were duplicate studies; we
identified 34 studies as potentially eligible for further screening. Thirty four articles were
fully assessed. Thirty one studies were excluded because they were of poor
methodological quality or because all three outcomes such as adverse respiratory
events, pain levels, and amount of pain medication used were not reported. One study
was excluded because it was written in Chinese and only the abstract was translated in
English. No English translation was available from any library source.
There are statistically significant differences between participants in the Dex group
compared to those in the control group. Participants in the Dex group reported reduced
pain levels (p= 0.0001), with fewer number of patients who received pain medications (p
= 0.0002), and fewer number of patients who experienced adverse respiratory events (p
= 0.0008) compared to those in the control group.
Conclusion: Dexmedetomidine when used during the perioperative period decreases
respiratory adverse events, overall use of narcotics, and pain levels in patients with
obstructive sleep apnea (OSA).
Implications Practice and Research: If clinicians integrate dexmedetomidine in
conjunction with general or local anesthesia, patients with OSA are able to tolerate
surgical procedures with less pain and without affecting their respiratory parameters.
Dexmedetomidine could become a useful adjuvant for patients with obstructive sleep
apnea who are susceptible to narcotic-induced respiratory depression. More research is
necessary involving large numbers of OSA patients.
Capstone Project: Evaluation of nursing dysphagia screening tools among patients
with stroke: A systematic review protocol
DNP Student: Farzaneh Raoufi
Abstract:
Background: Dysphagia screening is essential in early recognition of patients with
dysphagia post stroke. The effectiveness of a dysphagia screening tool is determined
by its reliability, validity and clinical utility. The Toronto Bedside Swallowing Screening
Test (TOR-BSST) and the 90-cc Water Swallow Test are appropriate for screening
dysphagia among patients with stroke, since both tools have been evaluated for
reliability and predictive validity.
Objective: The objective of this systematic review was to evaluate the effectiveness of
two bedside screening tools used by nurses to assess for dysphagia among
hospitalized adult patients with stroke. The two screening tools discussed were the
TOR-BSST and the 90-cc Water Swallow Test.
Inclusion Criteria:
Types of Participants: Participants were adult patients screened for dysphagia, aged
18 years and over, who were admitted to an inpatient unit within a hospital. Patients
with active dysphagia and pneumonia present on admission were excluded.
Types of Interventions: Studies that provided information about the diagnostic
accuracy of the TOR-BSST and the 90-cc Water Swallow Test in adults following stroke
were considered for retrieval. Studies were included that Video-Fluoroscopy (VF) or
Fibreoptic Endoscopic Evaluation of Swallowing (FEES) as the gold standard for
identification of dysphagia and silent aspiration.
Types of Outcomes: Outcomes included reliability (test-re-test, intra and inter-rater),
validity (specificity and sensitivity), as well as Positive Predictive Value (PPV) and
Negative Predictive Values (NPV).
Types of Studies: Experimental study designs included randomized controlled trials,
quasi-experimental; cohort and case-control studies. Cross-sectional observational
studies were also considered for inclusion and conclusion
Search Strategy: All studies, published and unpublished, in English and translated into
English that were conducted between 2007 and 2014 were selected for retrieval.
Methodological Quality: Papers selected for retrieval were assessed by two
independent reviewers for methodological validity prior to inclusion in the review using
the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist (Appendix
VI) as well as JBI Critical Appraisal Checklist for Descriptive/Case Series (Appendix VI).
Data Collection/Data Extraction: Data were extracted from papers included in the
review using the Standardized Standards for Reporting of Diagnostic Accuracy
(STARD) checklist (Appendix XI). RefWorks (ProQuest LLC) was utilized to store and
manage the search results from all included databases.
Data Synthesis: A meta-analysis was not possible, because the search resulted in
only two studies with different screening techniques.
Results: 660 studies were retrieved; of which 203 were duplicate studies. Of the 457
studies, 447 studies were excluded because they did not meet the inclusion criteria. Ten
studies were selected for review due to their methodological rigor. Eight studies were
excluded because the screening was not conducted by nurses, reliability/validity was
not tested and/or patients with stroke were not included in the sample. Two studies
were included in the final analysis.
The results of the included studies demonstrated:
Both the TOR-BSST and the 90-cc Water Swallow Test have high sensitivity. However,
the 90-cc Water Swallow Test has a low specificity.
The TOR-BSST and the 90-cc Water Swallow Test are reliable, easy to use and quick
to perform. The 90-cc Water Swallow Test is non-proprietary. The TOR-BSST is copyrighted and training may take up to 4 hours.
Conclusions: The psychometric characteristics of a bedside dysphagia screening tool,
including reliability, validity and feasibility of implementation are important factors to
consider in selecting a dysphagia screening tool in any clinical setting.
Capstone Project: Pilates Cadillac for Chronic Low Back Pain: A Pilot Study
DNP Student: Dana Stieglitz (Recipient of 2014 Outstanding DNP Student Award)
Abstract:
Background: Musculoskeletal health problems such as low back pain contribute
significantly to morbidity in the general population and contribute to the high costs of
health care in the industrialized world. Pilates is an evidence-based form of therapeutic
exercise found to improve low back pain and is underutilized in the healthcare setting.
Purpose: The purpose of this pilot study is to investigate the feasibility, acceptability,
and effectiveness of Pilates exercise on the Cadillac exercise machine as a therapeutic
intervention for chronic low back pain and disability.
Methods: The study was quasi-experimental one-group pre test post test pilot study
evaluating the effectiveness of a Pilates protocol using the Cadillac exercise machine to
decrease levels of pain, and increase function. Data were extracted from a SPSS
analysis of a pain visual analog scale (VAS) and Oswestry disability index (ODI).
Results: The results indicate that the Pilates intervention was effective for reducing
pain and improving function. VAS before the intervention were M = 41.83 ± 13.12 and
after the intervention were M = 11.08 ± 19.49. The mean difference calculated was
30.75 ± 20.27, CI = 43.63, 17.87, p < 0001. ODI scores before the intervention were M
= 23.83 ± 16.57 and after the intervention M = 12.58 ± 12.29, respectively. The mean
difference calculated from the paired t test from before and after the intervention was
11.25 ± 13.20, CI =19.64, -2.86, P < .02.
Conclusions: The results of this study will inform clinical practice recommendations
and direct subsequent research.
Capstone Project: Peer support for the Second Victim sponsored by the local
American Association of Critical Care Nurses Chapter: A Pilot Study
DNP Student: Sara Warth
Abstract:
Objective: The registered nurse who has committed a medical error can experience a
cascade of problems that have mental, emotional, and physical effects. This
experience has been termed the Second Victim Phenomenon. While the phenomenon
is described frequently in medical literature, effective treatments for the sufferer have
yet to be evaluated. Intentional one-to-one peer support may provide effective
treatment.
Method: A feasibility study offering a one-month peer support intervention within the
local American Association of Critical Care Nurses was completed. Fourteen subjects
who work in an adult Intensive Care Unit self-reported symptoms of Second Victim
Phenomenon and participated in the study. Specific outcomes measured include the
development of coping skills, and a reduction in the distress associated with a
committed medical error by the individual. Evaluation tools utilized were the Brief
COPE Inventory, and the Impact of Event Scale – Revised.
Results: Four scales on the Brief COPE demonstrated a statistically significant change
from the pre-test to the post-test: self-blame, religion, planning and venting. There was
no statistically significant change noted on the Impact of Event Scale - Revised.
Conclusions: Results suggest that one-to-one peer support offered through a
professional organization may be beneficial to the development of coping skills. Further
research is necessary to evaluate of the effectiveness of peer support programs for the
second victim.