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Noteworthy references
No+ewor+hy referen
"Of Nussing Practice and Nurse Practitioners," Louise C Rosasco. Hospitals, 48 (June 1974) 107-110. It i s difficult for nurses to perform as re-
quired in a society that views them as dependent on medical directions and performers only of physical comfort measures. It has become necessary to identify, describe, and categorize today's nursing practice to develop educational and experiential requirements for nurses and to educate other health care professionals and technicians, as well as the public. The nursing profession, as well as administration and medicine, must recognize that direct patient care by nurses encompasses the responsibility to identify, assess, and resolve health problems. Nursing practice i s not the provision of service to health care institutions or to other members of the health care team, but rather the provision of services to patients. A nurse may be a direct or an indirect nurse practitioner. The direct nurse practitioner personally renders care to patients. The indirect nurse practitioner affects nursing practice, the preparation of nurse practitioners, and the methods and vehicles through which nursing care is rendered. Each nurse practitioner must acquire and maintain nursing expertise to perform effectively and efficiently in her selected role, be it a direct or an indirect one. One cannot practice nursing on any level
without performing both "technical" and "professional" aspects of nursing. The degree to which the nurse practitioner uses her technical skills and professional skills will depend upon her level of nursing practice. If one takes a long, hard look at the nursing profession, the following conclusions can be drawn: 0 A well-informed society is demanding the ultimate in health care and service, which includes the expanding role of the nurse as an expert practitioner, a health teacher, and a functioning member of the community. 0 The need for the nursing professions to contribute to solving increasingly complex health care delivery problems requires that nurses have a high-level preparation in administrative, educational, and research skills, as well as in nursing practice. 0 Tasks of a nonclinical nature remain with nursing while some patient-oriented procedures formerly performed by nurses are being performed by nonnursing personnel. 0 Nurses are performing functions once considered to be the duty and respondbility of physicians. 0 The increasing complexity and sophistication of equipment used by nurses requires an indepth knowledge of scientific principles and technological skills.
AORN Journal, December 1974, Vol20, No 6
Ruth M Stone, RN Freeport, Tex
1073
"Total Knee Replacement," Charles Townley, Leslie Hill. The American Journal of Nursing, 74 (September 1974) 1612-1617. Arthroplasty, the surgical restoration of a joint, i s performed to relieve pain and restore joint mobility and stability. It can involve one joint surface (hemiarthroplasty) or both (total arthroplasty). Unicompartmental arthroplasty refers to the medical or lateral compartments of the knee joints. Total joint replacement using acrylic resins, practical due to the total hip arthroplasty efforts of Charnley, has been recently adapted to the knee. The destructive process of the knee joint is self-perpetuating. Joint surface defects, regardless of the cause, roughen the surface and reduce the efficiency of the lubrication. Inflammatory processes, such as rheumatoid arthritis, primarily involve articular cartilage softening. Rheumatic and degenerative arthritis, and severe joint distortion are indications for total knee replacement. The use of the procedure i s limited because of its finality and the present uncertainty of its longevity. The patient is directly involved in the preparation of his surgery beginning with office consultation. This team approach bolsters the patient's confidence. The anatomic total knee joint arthroplasty has three basic components. A metallic femoral prosthesis replaces the articular surface of the distal femur; a polyethylene plateau replaces the superior surface of the tibia; and an acrylic resin, methylmethacrylate, i s used to cement the prosthetic components in place. The prostheses preserve the stabilizing ligaments and the single-unit conjoinal design provides anchoring stability and simplicity of insertion. The knee joint is not as adaptable to total replacement as the hip because of its joint pattern and the critical importance of stability. The use of an anatomically oriented prosthesis and careful realignment of joint stress can minimize the disadvantages of the procedure. Provision of an articulating sur-
1074
face for the patella on the femoral component will eliminate a major source of pain, anterior-compartment fibrosis, and limited joint motion. In over 50 of the author's patients, pain was relieved and a t least 90% of stable motion and unsupported ambulation was achieved. The procedure i s new and untested b y time. It is limited primarily to older patients with limited demands on stress and longevity. Additional experience and time will gradually broaden the indications for total knee replacement.
Elizabeth A Reed, RN Philadelphia
"A Better Nurse=doctorRelationship," Jean Raisler. Nursing '74,
4 (September
1974) 21-23. Before free, two-way communications between nurses and doctors can b e achieved, nurses must first recognize how and why present interactions occur. It i s unusual for nurses and doctors to confer about patient care or to share knowledge about patient care except through written notes and orders. The only real communication often follows stereotyped roles. In this "transactional neurosis," the nurse passively accepts orders while actually making recommendations for patient care, allowing the physician to use them as his observations. In addition, most nurses will not criticize or contradict a physician even when he is making a mistake. Most physicians perceive health care workers as working for them, rather than the institution, and have little regard for nurses as coprofessionals. Nurses tend to internalize the role of the deferential subordinate, and physicians reinforce this view. This role prevents the nurse from effectively using her creativity, intelligence, and judgment and causes an inner conflict which can have unfortunate consequences for both the nurse and the patient. The anxiety that the
AORN Journal, December 1974, VoZ 20, N o 6
nurse feels when deference to the physician conflicts with her sense of professional responsibility can interfere with her ability to give good nursing care. The nurse-doctor relationship resembles the male-female dynamic in our society and i s also affected by social class, education and relative roles in hospital organization and power structure. The women's liberation movement and the push in nursing for professional autonomy should begin to affect the traditional relationship. Also, more nurses ore coming from the middle class and nursing i s moving into the university setting. This may help to reduce the socio-economic and educational differences that have existed. The bureaucratic structure of the hospital itself impedes better nurse-doctor relations. The physician has more mobility and greater opportunity to interact with department heads and administration. The nurse, as an employee of the institution, can only communicate through established bureaucratic channels. As nurses become more educated, they will become more aggressive and independent and will resist the traditional pattern of medical authoritarianism and nursing subservience.
Elizabeth A Reed, RN Philadelphia
"Adiuncts to the Abdominal Wall Re= construction Following Extensive Cancer Surgery," Tomoo Tajima, John C McDonald. Surgery, 76 (August 1974) 259-
262. The authors describe the successful use of Marlex mesh, porcine xenograft, and autogenous split-thickness skin graft t o reconstruct the abdominal wall following extensive cancer surgery. The patient, a female of 49 years, was admitted with considerable weight loss and a large mass in the right lower abdomen that was slightly fluctuant, tender, and adhered to
1076
the anterior abdominal wall. The initial operation was perfbrmed for an appendiceal abscess. The abscess was drained, but the drain site did not completely heal. As the disease progressed, multiple colocutaneous fistulas were exhibited on fistulograms. The second operation was extensive. Because of the attachment to the abdominal wall and the colocutaneous fistula tracts, the wide excision of the abdominal wall required grafting. The decision on closure was to cover the defect with a sheet of Marlex mesh. This was sutured to the facia and covered with a bulky dressing. During the two days postopetatively, a generous amount of peritoneal fluid was lost via the mesh. This prompted the application of a porcine xenograft, which stopped the flow. By the 21st postoperative day, granulation tissue had filled and completely covered the interstices of the mesh. At this point autogenous split-thickness skin grafts were successfully applied. The patient was discharged six days postgrafting. Nineteen months later, she showed no evidence of disease. The advantage of using the porcine xenograft as a biological dressing was the immediate arrest of the loss of peritoneal fluid. This also fostered decreased pain, increased mobility, prevented infection, and decreased the time to autografting. The temporary application of heterograft coverage of the wound until the maximum readiness for autografting may prove an advantageous innovation.
Fannie Hadley, RN Bronx, N Y "Computer-assisted Tomography: I t s Place in Investigation of Suspected Intracranlal Tumors," J Gawler, et al. The Lancet, 2 (August 1974) 419-423. Diagnosis of intracranial tumor i s most difficult and usually requires many diagnostic
AORN Journal, December 1974, V o l 2 0 , N o 6
procedures. A dramatic change i n the established investigative procedure has been brought about b y computer-assisted transverse axial tomography (ct scanning). Using a finely collimated x-ray beam, transverse axial "slices" of the head are scanned. Two x-ray detectors are mounted along the vertical axis of the head. The x-ray beam and detectors scan across the head in a linear fashion a t one-degree intervals for a full 180 degrees. Each detector makes 160 readings at each onedegree interval. A computer mathematically evaluates the data obtained and displays the information on an oscilloscope which contrasts areas of different density. The display i s photographed a t intervals to provide a pictorial record. Deviations or abnormalities from normal brain tissue are considered pathalogical disease entities. Even when a tumor has a density similar to that of normal brain tissue, i t s presence i s indicated by hydrocephalus, deformity of the tumor site, and/or a shift of midline structures, In this manner, cerebral atrophy and infarctions can also be recognized b y the c t scanner. A most gratifying feature of the c t scanner i s its definite diagnosis of tumor along with its exact size and location a t the first investigation. Other screening proceduresplain x-ray, pneumoencephalography, isatope brain scans-can show "suspicious" results that present problems in patient management. The patient is subjected to further investigations that are expensive, uncomfortable, contain hazardous risks, and often require general anesthetic.
Opal L Conerly, RN Alexandria, l a
"Emerging Concepts in the Control of Surgical Infections," J Wesley Alexander. Surgery, 75 (June 1974) 934-946. Surgical infections continue to be a major problem in spite of the explosion of scientific knowledge that has improved
1078
methods of surgical practice. Even though attention has been directed toward the management of nosocomial infections since the beginning of the 20th century, no dramatic breakthrough has been discovered in the prevention or treatment of these infections. The use of antimicrobial agents has been helpful in selected instances, but has also had deleterious effects and made the problem even more complex. Studying the immune defense mechanisms of the host may provide valuable information i n the management of surgical and nosocomial infections. Highly interdependent, these immune defense mechanisms can be separated into three categories including the phagocytic cells, the opsonins, and the vascular response. Transfusion of leukocytes has proven beneficial in patients experiencing chemotherepeutic-induced bone marrow depression. Also, abnormalities of neutrophil function can b e prevented through nutritional supplementation. Activation of macrophages may lead to increased resistance in patients with defined depression of the reticuloendothelial system activity. The complex system of serum proteins or opsonins affects the efficiency of phagocytic cells and consists of antibodies with other less clearly defined serum proteins. The effectiveness of active vaccination and the passive administration of hyperimmune globulin i s documented, one of the recent developments being a poly-valent vaccine used to immunize burn patients against Pseudomonas aeruginosa and to combat Pseudomonas bacteremia in burn patients. An alternate pathway or bypass mechanism has been identified, which appears to b e responsible for many of the deficiencies of host resistance not previously understood. Vascular response from diminished perfusion of blood to tissues in the presence of severe infections markedly affects cellular function b y releasing substances from anoxic or dead cells. Bacteria activate multiple complex systems which affect altered
AORN Journal, December 1974, V o l 2 0 , N o 6
nutrient flow, compounding the problem. Current progress in clinical and basic research pertaining to surgical infections suggests that emphasis on immunological mechanisms i s appropriate and may provide new methods of combating nosocomial and surgical infections.
"Factors Predisposing to Baeteriuria During Indwelling Urethral Catheterization," Richard Garibaldi, et al. New
Dimensions in Health Service (August 1974) 40-4 1. Experts in Canada and the United States suggest that nearly 50% of all surgery now performed in hospitals could be done on a come-and-go basis. In both countries, physicians receive many pressures to avoid come-and-go surgery. The major problem i s the threat of malpractice suits. To date, mortality rates have been virtually zero. Some of the factors that are stimulating the trend to outpatient surgery include freeing beds for seriously ill patients, lower cost to patients, less psychological trauma to patients and their families possible quicker refurn to employment, and less likelihood to acquiring infections. Hospitals can help promote outpatient surgery by assisting surgeons in meeting their administrative needs, providing facilities that promote efficient use of time, revising policies that require inpatient hospitalization of patients for most surgical procedures, and providing information necessary for billing procedures. Unless hospitals make their facilities available, there will be an upsurge in nonhospital surgical facilities challenging the hospital and competing for patients. Hospitals can do the job if they establish outpatient surgery as a priority objective. They have the facilities and personnel and can acquire the needed managerial expertise.
England Journal of Medicine, 291 (August 1974) 215-219. Despite the use of closed sterile drainage systems to prevent urinary-tract infections during indwelling bladder catheterization, over 20% of patients receiving this treatment acquire catheter-associated bacteriuria. Recent surveys indicate that these infections account for more than 30% of reported nosocomial infections, suggesting that either closed sterile urinary drainage techniques are not being properly adhered to or that new problems have arisen which increased the development of infection. Hospital environment influences incidence of infections. Catheter-associated bacteriuria were highest for medical, neurosurgical, and orthopedic/surgical patients, whereas, the lowest incidence was noted in obstetric and gynecologic patients. Increased infection rates were also related to sex and age of patients as well as to the severity of underlying disease in nonsurgical patients. Patients receiving systemic antibiotics showed reductions in rates of bacteriuria; however, the medication seemed to influence the type of organism involved. The increased rates of bacteriuria following recognized breaks in management reflect the problems of maintaining strict sterile technique i n patient care in general hospital situations. Failure to adhere to good principles of management can be an important cause of morbidity, prolonged hospitalization, and death from Gram-negative rod bacteremia. Each patient should be evaluated on an individual basis to determine the risks versus the benefits of inserting an indwelling catheter, and if catheterized, the catheter should be removed as soon as possible to avoid complications of bacteriuria.
Sister Kane, RHSJ, RN, MEd
Doris MacClelland, RN
Amhersf View, Onfario
Son Diego, Calif
Doris MacClelland, RN, MS Son Diego, Calif
"Future Trends in Ambulatory Shortstay Surgery," Thomas R O'Donovan.
1080
AORN Journal, December 1974, Vol20, N o 6
"Of Nussing Practice and Nurse Practitioners," Louise C Rosasco. Hospitals, 48 (June 1974) 107-110. It i s difficult for nurses to perform as re-
quired in a society that views them as dependent on medical directions and performers only of physical comfort measures. It has become necessary to identify, describe, and categorize today's nursing practice to develop educational and experiential requirements for nurses and to educate other health care professionals and technicians, as well as the public. The nursing profession, as well as administration and medicine, must recognize that direct patient care by nurses encompasses the responsibility to identify, assess, and resolve health problems. Nursing practice i s not the provision of service to health care institutions or to other members of the health care team, but rather the provision of services to patients. A nurse may be a direct or an indirect nurse practitioner. The direct nurse practitioner personally renders care to patients. The indirect nurse practitioner affects nursing practice, the preparation of nurse practitioners, and the methods and vehicles through which nursing care is rendered. Each nurse practitioner must acquire and maintain nursing expertise to perform effectively and efficiently in her selected role, be it a direct or an indirect one. One cannot practice nursing on any level
without performing both "technical" and "professional" aspects of nursing. The degree to which the nurse practitioner uses her technical skills and professional skills will depend upon her level of nursing practice. If one takes a long, hard look at the nursing profession, the following conclusions can be drawn: 0 A well-informed society is demanding the ultimate in health care and service, which includes the expanding role of the nurse as an expert practitioner, a health teacher, and a functioning member of the community. 0 The need for the nursing professions to contribute to solving increasingly complex health care delivery problems requires that nurses have a high-level preparation in administrative, educational, and research skills, as well as in nursing practice. 0 Tasks of a nonclinical nature remain with nursing while some patient-oriented procedures formerly performed by nurses are being performed by nonnursing personnel. 0 Nurses are performing functions once considered to be the duty and respondbility of physicians. 0 The increasing complexity and sophistication of equipment used by nurses requires an indepth knowledge of scientific principles and technological skills.
AORN Journal, December 1974, Vol20, No 6
Ruth M Stone, RN Freeport, Tex
1073
"Total Knee Replacement," Charles Townley, Leslie Hill. The American Journal of Nursing, 74 (September 1974) 1612-1617. Arthroplasty, the surgical restoration of a joint, i s performed to relieve pain and restore joint mobility and stability. It can involve one joint surface (hemiarthroplasty) or both (total arthroplasty). Unicompartmental arthroplasty refers to the medical or lateral compartments of the knee joints. Total joint replacement using acrylic resins, practical due to the total hip arthroplasty efforts of Charnley, has been recently adapted to the knee. The destructive process of the knee joint is self-perpetuating. Joint surface defects, regardless of the cause, roughen the surface and reduce the efficiency of the lubrication. Inflammatory processes, such as rheumatoid arthritis, primarily involve articular cartilage softening. Rheumatic and degenerative arthritis, and severe joint distortion are indications for total knee replacement. The use of the procedure i s limited because of its finality and the present uncertainty of its longevity. The patient is directly involved in the preparation of his surgery beginning with office consultation. This team approach bolsters the patient's confidence. The anatomic total knee joint arthroplasty has three basic components. A metallic femoral prosthesis replaces the articular surface of the distal femur; a polyethylene plateau replaces the superior surface of the tibia; and an acrylic resin, methylmethacrylate, i s used to cement the prosthetic components in place. The prostheses preserve the stabilizing ligaments and the single-unit conjoinal design provides anchoring stability and simplicity of insertion. The knee joint is not as adaptable to total replacement as the hip because of its joint pattern and the critical importance of stability. The use of an anatomically oriented prosthesis and careful realignment of joint stress can minimize the disadvantages of the procedure. Provision of an articulating sur-
1074
face for the patella on the femoral component will eliminate a major source of pain, anterior-compartment fibrosis, and limited joint motion. In over 50 of the author's patients, pain was relieved and a t least 90% of stable motion and unsupported ambulation was achieved. The procedure i s new and untested b y time. It is limited primarily to older patients with limited demands on stress and longevity. Additional experience and time will gradually broaden the indications for total knee replacement.
Elizabeth A Reed, RN Philadelphia
"A Better Nurse=doctorRelationship," Jean Raisler. Nursing '74,
4 (September
1974) 21-23. Before free, two-way communications between nurses and doctors can b e achieved, nurses must first recognize how and why present interactions occur. It i s unusual for nurses and doctors to confer about patient care or to share knowledge about patient care except through written notes and orders. The only real communication often follows stereotyped roles. In this "transactional neurosis," the nurse passively accepts orders while actually making recommendations for patient care, allowing the physician to use them as his observations. In addition, most nurses will not criticize or contradict a physician even when he is making a mistake. Most physicians perceive health care workers as working for them, rather than the institution, and have little regard for nurses as coprofessionals. Nurses tend to internalize the role of the deferential subordinate, and physicians reinforce this view. This role prevents the nurse from effectively using her creativity, intelligence, and judgment and causes an inner conflict which can have unfortunate consequences for both the nurse and the patient. The anxiety that the
AORN Journal, December 1974, VoZ 20, N o 6
nurse feels when deference to the physician conflicts with her sense of professional responsibility can interfere with her ability to give good nursing care. The nurse-doctor relationship resembles the male-female dynamic in our society and i s also affected by social class, education and relative roles in hospital organization and power structure. The women's liberation movement and the push in nursing for professional autonomy should begin to affect the traditional relationship. Also, more nurses ore coming from the middle class and nursing i s moving into the university setting. This may help to reduce the socio-economic and educational differences that have existed. The bureaucratic structure of the hospital itself impedes better nurse-doctor relations. The physician has more mobility and greater opportunity to interact with department heads and administration. The nurse, as an employee of the institution, can only communicate through established bureaucratic channels. As nurses become more educated, they will become more aggressive and independent and will resist the traditional pattern of medical authoritarianism and nursing subservience.
Elizabeth A Reed, RN Philadelphia
"Adiuncts to the Abdominal Wall Re= construction Following Extensive Cancer Surgery," Tomoo Tajima, John C McDonald. Surgery, 76 (August 1974) 259-
262. The authors describe the successful use of Marlex mesh, porcine xenograft, and autogenous split-thickness skin graft t o reconstruct the abdominal wall following extensive cancer surgery. The patient, a female of 49 years, was admitted with considerable weight loss and a large mass in the right lower abdomen that was slightly fluctuant, tender, and adhered to
1076
the anterior abdominal wall. The initial operation was perfbrmed for an appendiceal abscess. The abscess was drained, but the drain site did not completely heal. As the disease progressed, multiple colocutaneous fistulas were exhibited on fistulograms. The second operation was extensive. Because of the attachment to the abdominal wall and the colocutaneous fistula tracts, the wide excision of the abdominal wall required grafting. The decision on closure was to cover the defect with a sheet of Marlex mesh. This was sutured to the facia and covered with a bulky dressing. During the two days postopetatively, a generous amount of peritoneal fluid was lost via the mesh. This prompted the application of a porcine xenograft, which stopped the flow. By the 21st postoperative day, granulation tissue had filled and completely covered the interstices of the mesh. At this point autogenous split-thickness skin grafts were successfully applied. The patient was discharged six days postgrafting. Nineteen months later, she showed no evidence of disease. The advantage of using the porcine xenograft as a biological dressing was the immediate arrest of the loss of peritoneal fluid. This also fostered decreased pain, increased mobility, prevented infection, and decreased the time to autografting. The temporary application of heterograft coverage of the wound until the maximum readiness for autografting may prove an advantageous innovation.
Fannie Hadley, RN Bronx, N Y "Computer-assisted Tomography: I t s Place in Investigation of Suspected Intracranlal Tumors," J Gawler, et al. The Lancet, 2 (August 1974) 419-423. Diagnosis of intracranial tumor i s most difficult and usually requires many diagnostic
AORN Journal, December 1974, V o l 2 0 , N o 6
procedures. A dramatic change i n the established investigative procedure has been brought about b y computer-assisted transverse axial tomography (ct scanning). Using a finely collimated x-ray beam, transverse axial "slices" of the head are scanned. Two x-ray detectors are mounted along the vertical axis of the head. The x-ray beam and detectors scan across the head in a linear fashion a t one-degree intervals for a full 180 degrees. Each detector makes 160 readings at each onedegree interval. A computer mathematically evaluates the data obtained and displays the information on an oscilloscope which contrasts areas of different density. The display i s photographed a t intervals to provide a pictorial record. Deviations or abnormalities from normal brain tissue are considered pathalogical disease entities. Even when a tumor has a density similar to that of normal brain tissue, i t s presence i s indicated by hydrocephalus, deformity of the tumor site, and/or a shift of midline structures, In this manner, cerebral atrophy and infarctions can also be recognized b y the c t scanner. A most gratifying feature of the c t scanner i s its definite diagnosis of tumor along with its exact size and location a t the first investigation. Other screening proceduresplain x-ray, pneumoencephalography, isatope brain scans-can show "suspicious" results that present problems in patient management. The patient is subjected to further investigations that are expensive, uncomfortable, contain hazardous risks, and often require general anesthetic.
Opal L Conerly, RN Alexandria, l a
"Emerging Concepts in the Control of Surgical Infections," J Wesley Alexander. Surgery, 75 (June 1974) 934-946. Surgical infections continue to be a major problem in spite of the explosion of scientific knowledge that has improved
1078
methods of surgical practice. Even though attention has been directed toward the management of nosocomial infections since the beginning of the 20th century, no dramatic breakthrough has been discovered in the prevention or treatment of these infections. The use of antimicrobial agents has been helpful in selected instances, but has also had deleterious effects and made the problem even more complex. Studying the immune defense mechanisms of the host may provide valuable information i n the management of surgical and nosocomial infections. Highly interdependent, these immune defense mechanisms can be separated into three categories including the phagocytic cells, the opsonins, and the vascular response. Transfusion of leukocytes has proven beneficial in patients experiencing chemotherepeutic-induced bone marrow depression. Also, abnormalities of neutrophil function can b e prevented through nutritional supplementation. Activation of macrophages may lead to increased resistance in patients with defined depression of the reticuloendothelial system activity. The complex system of serum proteins or opsonins affects the efficiency of phagocytic cells and consists of antibodies with other less clearly defined serum proteins. The effectiveness of active vaccination and the passive administration of hyperimmune globulin i s documented, one of the recent developments being a poly-valent vaccine used to immunize burn patients against Pseudomonas aeruginosa and to combat Pseudomonas bacteremia in burn patients. An alternate pathway or bypass mechanism has been identified, which appears to b e responsible for many of the deficiencies of host resistance not previously understood. Vascular response from diminished perfusion of blood to tissues in the presence of severe infections markedly affects cellular function b y releasing substances from anoxic or dead cells. Bacteria activate multiple complex systems which affect altered
AORN Journal, December 1974, V o l 2 0 , N o 6
nutrient flow, compounding the problem. Current progress in clinical and basic research pertaining to surgical infections suggests that emphasis on immunological mechanisms i s appropriate and may provide new methods of combating nosocomial and surgical infections.
"Factors Predisposing to Baeteriuria During Indwelling Urethral Catheterization," Richard Garibaldi, et al. New
Dimensions in Health Service (August 1974) 40-4 1. Experts in Canada and the United States suggest that nearly 50% of all surgery now performed in hospitals could be done on a come-and-go basis. In both countries, physicians receive many pressures to avoid come-and-go surgery. The major problem i s the threat of malpractice suits. To date, mortality rates have been virtually zero. Some of the factors that are stimulating the trend to outpatient surgery include freeing beds for seriously ill patients, lower cost to patients, less psychological trauma to patients and their families possible quicker refurn to employment, and less likelihood to acquiring infections. Hospitals can help promote outpatient surgery by assisting surgeons in meeting their administrative needs, providing facilities that promote efficient use of time, revising policies that require inpatient hospitalization of patients for most surgical procedures, and providing information necessary for billing procedures. Unless hospitals make their facilities available, there will be an upsurge in nonhospital surgical facilities challenging the hospital and competing for patients. Hospitals can do the job if they establish outpatient surgery as a priority objective. They have the facilities and personnel and can acquire the needed managerial expertise.
England Journal of Medicine, 291 (August 1974) 215-219. Despite the use of closed sterile drainage systems to prevent urinary-tract infections during indwelling bladder catheterization, over 20% of patients receiving this treatment acquire catheter-associated bacteriuria. Recent surveys indicate that these infections account for more than 30% of reported nosocomial infections, suggesting that either closed sterile urinary drainage techniques are not being properly adhered to or that new problems have arisen which increased the development of infection. Hospital environment influences incidence of infections. Catheter-associated bacteriuria were highest for medical, neurosurgical, and orthopedic/surgical patients, whereas, the lowest incidence was noted in obstetric and gynecologic patients. Increased infection rates were also related to sex and age of patients as well as to the severity of underlying disease in nonsurgical patients. Patients receiving systemic antibiotics showed reductions in rates of bacteriuria; however, the medication seemed to influence the type of organism involved. The increased rates of bacteriuria following recognized breaks in management reflect the problems of maintaining strict sterile technique i n patient care in general hospital situations. Failure to adhere to good principles of management can be an important cause of morbidity, prolonged hospitalization, and death from Gram-negative rod bacteremia. Each patient should be evaluated on an individual basis to determine the risks versus the benefits of inserting an indwelling catheter, and if catheterized, the catheter should be removed as soon as possible to avoid complications of bacteriuria.
Sister Kane, RHSJ, RN, MEd
Doris MacClelland, RN
Amhersf View, Onfario
Son Diego, Calif
Doris MacClelland, RN, MS Son Diego, Calif
"Future Trends in Ambulatory Shortstay Surgery," Thomas R O'Donovan.
1080
AORN Journal, December 1974, Vol20, N o 6