Purpose. The purpose of this paper is to analyze the concept of scope of practice for occupationa... more Purpose. The purpose of this paper is to analyze the concept of scope of practice for occupational health nurses. Background. Occupational health nurses (OHNs) practice in different industries alone or with other nurses, providing care to employees. The demand on occupational health nurses to respond to increasing organizational healthcare needs of employees and other healthcare demands raises the question, do occupational health nurses understand their scope of practice? Occupational health nurses inadvertently practicing outside their scope may jeopardize their nursing licenses, and the safety and quality of care of employees. Method. A literature review was conducted to identify defining attributes, antecedents, and consequences for the concept of scope of practice for OHNs. Walker and Avant’s eight-step framework for concept analysis was applied. Results. The defining attributes of the scope of practice for OHN include but are not limited to standards and guidelines: competency,...
The purpose of this study was to determine the impact of baseline systemic inflammation (pro-infl... more The purpose of this study was to determine the impact of baseline systemic inflammation (pro-inflammatory cytokine, anti-inflammatory cytokine, and their ratio), genetic variability, and environment on the development of health care associated infections (HAI) among sepsis patients during their ICU stay (up to 28 days). Methods: A prospective observation study was conducted at the Veterans Affairs Medical Center in the Medical Intensive Care Unit over an 18 month period. A total of 78 patients were enrolled within 72 hours of presenting to the ICU with sepsis. Patient were excluded if they were receiving immunosuppressants (chemotherapy or greater than one mg/kg of prednisone or equivalent dose), immunosuppressed (AIDS, cancer), or had liver failure (Child Pugh category C or higher). Baseline plasma and buccal swabs were collected. Patients were followed prospectively through their ICU stay (or for a maximum of 28 days) for the development of HAI as defined by CDC guidelines. Primary variables included baseline IL-6 and IL-10 levels, IL-6 SNP rs1800795, IL-10 SNP rs1800896, APACHE II, invasive devices, and development of HAI. Results: A total of 17 HAI were identified with 64% caused by Candida. There were no significant differences in levels of pro-inflammatory cytokine, anti-inflammatory cytokine, or their ratio among subjects who did and did not develop at least one HAI during their ICU stay. There were also no significant differences in rs1800795 or rs1800896 genotypes for those who did and did not develop HAI; however, racial differences were detected in genotypes among white and black patients with sepsis who did and did not develop HAI. There was a significant difference in rs1800795 genotype among black patients with sepsis who did not develop HAI compared to whites patients with sepsis who did not develop HAI (p = 0.006). Specifically, black patients had a lower CG (17.4% vs. 42.1%) and higher GG (82.6% vs. 42.1%) than white patients. There were no racial differences when comparing white and black sepsis patients who developed HAI (p = 1.0). In a series of Cox regression analyses investigating timing to first HAI among those who did and did not develop HAI during ICU stay, the final model included only APACHE II, cumulative invasive device score, and IL-6 rs1800795. Conclusion: This study provides evidence of a genetic risk for development of HAI. Despite best evidenced based practices some patients will develop HAI. Strict aseptic technique is essential to preventing infection. In addition to eliminating invasive devices as quickly as possible, patients with a high severity of illness may need to be isolated to lower their risk. Early administration of antibiotics not only provides prompt treatment for the initial infection but also lowers risk for subsequent infections. vii TABLE OF CONTENTS CHAPTER 1.
The description of a monoclonal mast cell activation syndrome in patients with anaphylaxis, who f... more The description of a monoclonal mast cell activation syndrome in patients with anaphylaxis, who fulfill one or two minor-criteria of mastocytosis, has led to a search for new unrecognized mast cell activation syndromes. New classification of mast cell diseases including well-known diseases is provided in order to be able to better recognize and describe new entities. The term mast cell activation has been defined by verifiable scientific objective and subjective criteria, and known and idiopathic mast cell activation syndromes have been classified. Mast cell activation cannot be defined by symptoms alone, as different diseases and conditions, including those with contribution of different cell types and somatization disorders may lead to similar symptoms. For this reason the preclinical checkpoint mast cell activation was defined to require typical symptoms in combination with demonstration of mast cell mediator release in (an acute) episode(s) as well as with a good response to mast cell mediator-directed therapy. Mast cell activation syndromes were classified in primary (e.g. mastocytosis), secondary (e.g. IgE-mediated allergy) and idiopathic forms. Only through a deeper understanding of mast cell diseases, can new previously unrecognized idiopathic mast cell activation syndrome entities be described and analyzed.
AIM To analyze and examine the concept of uncertainty of the patient's illness among family c... more AIM To analyze and examine the concept of uncertainty of the patient's illness among family caregivers. BACKGROUND Promoting family caregivers' health is significant in nursing. Family caregivers may experience uncertainty related to their loved ones' illness. A lack of clarity exists regarding the uncertainty concept among family caregivers and its implications in nursing. DATA SOURCE A review of the literature that focused on family caregivers of adult patients using PubMed, CINAHL, and Scopus databases was completed. METHODS The Walker and Avant framework was applied to identify the attributes, antecedents, and consequences of family caregivers' uncertainty. RESULTS Eight articles were analyzed. Attributes of family caregivers' uncertainty included the patient's illness probability and family caregivers' perception of the illness. Antecedents included the characteristics of the patient's illness, factors associated with the family caregivers' perception of the illness, and family responsibilities of caregiving. The consequences included family caregivers' emotional, psychological, and financial outcomes. Family caregivers' uncertainty is defined as the perception of the inability to process information regarding the patient's illness trajectory when caring for significant others' illness. CONCLUSIONS Individuals can perceive uncertainty differently as a patient-facing uncertainty in illness versus a family caregiver facing uncertainty of their loved ones' illness.
Background Delirium as a sudden cognitive and behavioral change can be traumatic for family careg... more Background Delirium as a sudden cognitive and behavioral change can be traumatic for family caregivers. An understanding of family caregivers’ experiences with delirium in their loved one in an intensive care unit (ICU) will help clinicians provide family-centered care. Objective To explore the impact of delirium on, and the needs of, family caregivers of ICU patients with delirium. Methods A comprehensive search was done of literature in the PubMed, CINAHL, and Scopus databases published from 2000 to 2020. Primary studies written in English and done in critical care settings were included. Studies that did not focus on the family experience of delirium were excluded. Additional studies were identified by reviewing the reference lists of selected articles. Evidence was synthesized, and common themes were identified. Results Among 210 studies, 7 were included after irrelevant and duplicate studies had been removed. Findings were categorized as (1) psychological impacts of a patient’s...
Introduction: Sepsis is frequent cause of ICU admission and a leading cause of morbidity and mort... more Introduction: Sepsis is frequent cause of ICU admission and a leading cause of morbidity and mortality. Early recognition and intervention are keys to a favorable outcome. Harnessing the electronic medical record (EMR) reduces provider and researcher burden in collecting/integrating data and will le
Introduction: Healthcare Associated Infections (HAI) are associated with increased cost, morbidit... more Introduction: Healthcare Associated Infections (HAI) are associated with increased cost, morbidity, and mortality. Risk factors for HAI are well established; however, the independent risk associated with an exaggerated inflammatory response has not been adequately studied. Hypothesis: The objective was to investigate baseline cytokine levels (IL-6, IL-10), their polymorphisms (RS1800795, RS1800896) and environment on the development of new HAI in ICU patients admitted with sepsis. Methods: This prospective observational study evaluated 78 patients admitted to ICU with early sepsis ( Results: Seventeen HAI were identified. The final regression model included APACHE II, invasive device score, antibiotics prior to ICU, and IL6 RS1800795. Based on the multivariate model, for every 1-point increase in APACHE II score there was a 3.4% increased risk for developing HAI. Cumulative invasive device score and early antibiotic use reduced the risk of HAI. In the univariate model, the presence ...
BackgroundIn hospitalized patients with COVID-19 pneumonia, progression to acute respiratory fail... more BackgroundIn hospitalized patients with COVID-19 pneumonia, progression to acute respiratory failure requiring invasive mechanical ventilation (MV) is associated with significant morbidity and mortality. Severe dysregulated systemic inflammation is the putative mechanism. We hypothesize that early prolonged methylprednisolone (MP) treatment could accelerate disease resolution, decreasing the need for ICU and mortality.MethodsWe conducted a multicenter, observational study to explore the association between exposure to prolonged, low-dose, MP treatment and need for ICU referral, intubation or death within 28 days (composite primary endpoint) in patients with severe COVID-19 pneumonia admitted to Italian respiratory high-dependency units. Secondary outcomes were invasive MV-free days and changes in C-reactive protein (CRP) levels.ResultsFindings are reported as MP (n=83) vs. control (n=90). The composite primary endpoint was met by 19 vs. 40 [adjusted hazard ratio (HR) 0.41; 95% confi...
Background: Central lineYassociated bloodstream infection (CLABSI) prevention efforts have increa... more Background: Central lineYassociated bloodstream infection (CLABSI) prevention efforts have increased over the past decade because of implications of the Affordable Care Act and mandatory reporting laws. These legislative measures allow for reduced reimbursement to hospitals with high level of CLABSIs and other health careYassociated infections. Objective: The aim of this study was to explore the impact of legislation and mandatory reporting on CLABSI rates and reporting. Methods: The study team performed a retrospective review of medical intensive care unit patients in January 2008, 2012, and 2015 to examine changes in CLABSI reporting by 2 methods (International Classification of Diseases [ICD] by providers and Centers for Disease Control by infection prevention [IP]), as well as changes in central line use over time. Data were summarized and compared. Percent agreement and. statistics were calculated for ICD-and IP-coded CLABSIs. Results: Among 465 intensive care unit patients, most were white (89.9%), males (52.0%), aged 58.7 T 17.1 years. Only 3 new CLABSIs were reported during the study period: 2 by ICD and IP in 2008, 1 by ICD in 2012, and 0 by either method in 2015. The percent agreement CLABSI Reporting
Background: Hospital mortality rates related to sepsis have decreased over the last decade, incre... more Background: Hospital mortality rates related to sepsis have decreased over the last decade, increasing the number of survivors of sepsis who may experience long-term consequences. Yet, little is known about how they perceive their illness experience and its aftermath. Objective: This study explores the experiences of sepsis survivors after 1 year of their index intensive care unit (ICU) stay. Methods: This phenomenological study was guided by Merleau-Ponty's philosophy. Participants were adult patients admitted directly to the medical ICU with sepsis who had an ICU stay of at least 48 hours and had been discharged from their index ICU stay for at least 1 year. Participants were invited by letter to participate in face-to-face or telephone interviews and a brief survey. Interviews were audio recorded, transcribed verbatim, and verified. An interpretive group read transcripts aloud to increase rigor of identifying meaning units, existential grounds, and thematic structure. Results: Eight participants were recruited over 20 months. Participants were primarily white (87.5%) females (75%) with an age range of 37 to 74 years who were interviewed between 1 and 2 years following an index sepsis ICU stay. Five major themes emerged from the transcripts: (1) how they survived, (2) blurring of time versus counting time by events, (3) helpful help versus unhelpful help, (4) powerless versus striving for control, and (5) survivor but not fully recovered. Discussion: Findings reflected a long trajectory of chronic illness in which the index episode of sepsis was not necessarily what stood out as figural to participants. The meaning of participant experiences must be considered in the context of a health care system that offers little to no systematic follow-up care after sepsis and little prevention. Participants expressed a need for advocacy and follow-up support.
Purpose. The purpose of this paper is to analyze the concept of scope of practice for occupationa... more Purpose. The purpose of this paper is to analyze the concept of scope of practice for occupational health nurses. Background. Occupational health nurses (OHNs) practice in different industries alone or with other nurses, providing care to employees. The demand on occupational health nurses to respond to increasing organizational healthcare needs of employees and other healthcare demands raises the question, do occupational health nurses understand their scope of practice? Occupational health nurses inadvertently practicing outside their scope may jeopardize their nursing licenses, and the safety and quality of care of employees. Method. A literature review was conducted to identify defining attributes, antecedents, and consequences for the concept of scope of practice for OHNs. Walker and Avant’s eight-step framework for concept analysis was applied. Results. The defining attributes of the scope of practice for OHN include but are not limited to standards and guidelines: competency,...
The purpose of this study was to determine the impact of baseline systemic inflammation (pro-infl... more The purpose of this study was to determine the impact of baseline systemic inflammation (pro-inflammatory cytokine, anti-inflammatory cytokine, and their ratio), genetic variability, and environment on the development of health care associated infections (HAI) among sepsis patients during their ICU stay (up to 28 days). Methods: A prospective observation study was conducted at the Veterans Affairs Medical Center in the Medical Intensive Care Unit over an 18 month period. A total of 78 patients were enrolled within 72 hours of presenting to the ICU with sepsis. Patient were excluded if they were receiving immunosuppressants (chemotherapy or greater than one mg/kg of prednisone or equivalent dose), immunosuppressed (AIDS, cancer), or had liver failure (Child Pugh category C or higher). Baseline plasma and buccal swabs were collected. Patients were followed prospectively through their ICU stay (or for a maximum of 28 days) for the development of HAI as defined by CDC guidelines. Primary variables included baseline IL-6 and IL-10 levels, IL-6 SNP rs1800795, IL-10 SNP rs1800896, APACHE II, invasive devices, and development of HAI. Results: A total of 17 HAI were identified with 64% caused by Candida. There were no significant differences in levels of pro-inflammatory cytokine, anti-inflammatory cytokine, or their ratio among subjects who did and did not develop at least one HAI during their ICU stay. There were also no significant differences in rs1800795 or rs1800896 genotypes for those who did and did not develop HAI; however, racial differences were detected in genotypes among white and black patients with sepsis who did and did not develop HAI. There was a significant difference in rs1800795 genotype among black patients with sepsis who did not develop HAI compared to whites patients with sepsis who did not develop HAI (p = 0.006). Specifically, black patients had a lower CG (17.4% vs. 42.1%) and higher GG (82.6% vs. 42.1%) than white patients. There were no racial differences when comparing white and black sepsis patients who developed HAI (p = 1.0). In a series of Cox regression analyses investigating timing to first HAI among those who did and did not develop HAI during ICU stay, the final model included only APACHE II, cumulative invasive device score, and IL-6 rs1800795. Conclusion: This study provides evidence of a genetic risk for development of HAI. Despite best evidenced based practices some patients will develop HAI. Strict aseptic technique is essential to preventing infection. In addition to eliminating invasive devices as quickly as possible, patients with a high severity of illness may need to be isolated to lower their risk. Early administration of antibiotics not only provides prompt treatment for the initial infection but also lowers risk for subsequent infections. vii TABLE OF CONTENTS CHAPTER 1.
The description of a monoclonal mast cell activation syndrome in patients with anaphylaxis, who f... more The description of a monoclonal mast cell activation syndrome in patients with anaphylaxis, who fulfill one or two minor-criteria of mastocytosis, has led to a search for new unrecognized mast cell activation syndromes. New classification of mast cell diseases including well-known diseases is provided in order to be able to better recognize and describe new entities. The term mast cell activation has been defined by verifiable scientific objective and subjective criteria, and known and idiopathic mast cell activation syndromes have been classified. Mast cell activation cannot be defined by symptoms alone, as different diseases and conditions, including those with contribution of different cell types and somatization disorders may lead to similar symptoms. For this reason the preclinical checkpoint mast cell activation was defined to require typical symptoms in combination with demonstration of mast cell mediator release in (an acute) episode(s) as well as with a good response to mast cell mediator-directed therapy. Mast cell activation syndromes were classified in primary (e.g. mastocytosis), secondary (e.g. IgE-mediated allergy) and idiopathic forms. Only through a deeper understanding of mast cell diseases, can new previously unrecognized idiopathic mast cell activation syndrome entities be described and analyzed.
AIM To analyze and examine the concept of uncertainty of the patient's illness among family c... more AIM To analyze and examine the concept of uncertainty of the patient's illness among family caregivers. BACKGROUND Promoting family caregivers' health is significant in nursing. Family caregivers may experience uncertainty related to their loved ones' illness. A lack of clarity exists regarding the uncertainty concept among family caregivers and its implications in nursing. DATA SOURCE A review of the literature that focused on family caregivers of adult patients using PubMed, CINAHL, and Scopus databases was completed. METHODS The Walker and Avant framework was applied to identify the attributes, antecedents, and consequences of family caregivers' uncertainty. RESULTS Eight articles were analyzed. Attributes of family caregivers' uncertainty included the patient's illness probability and family caregivers' perception of the illness. Antecedents included the characteristics of the patient's illness, factors associated with the family caregivers' perception of the illness, and family responsibilities of caregiving. The consequences included family caregivers' emotional, psychological, and financial outcomes. Family caregivers' uncertainty is defined as the perception of the inability to process information regarding the patient's illness trajectory when caring for significant others' illness. CONCLUSIONS Individuals can perceive uncertainty differently as a patient-facing uncertainty in illness versus a family caregiver facing uncertainty of their loved ones' illness.
Background Delirium as a sudden cognitive and behavioral change can be traumatic for family careg... more Background Delirium as a sudden cognitive and behavioral change can be traumatic for family caregivers. An understanding of family caregivers’ experiences with delirium in their loved one in an intensive care unit (ICU) will help clinicians provide family-centered care. Objective To explore the impact of delirium on, and the needs of, family caregivers of ICU patients with delirium. Methods A comprehensive search was done of literature in the PubMed, CINAHL, and Scopus databases published from 2000 to 2020. Primary studies written in English and done in critical care settings were included. Studies that did not focus on the family experience of delirium were excluded. Additional studies were identified by reviewing the reference lists of selected articles. Evidence was synthesized, and common themes were identified. Results Among 210 studies, 7 were included after irrelevant and duplicate studies had been removed. Findings were categorized as (1) psychological impacts of a patient’s...
Introduction: Sepsis is frequent cause of ICU admission and a leading cause of morbidity and mort... more Introduction: Sepsis is frequent cause of ICU admission and a leading cause of morbidity and mortality. Early recognition and intervention are keys to a favorable outcome. Harnessing the electronic medical record (EMR) reduces provider and researcher burden in collecting/integrating data and will le
Introduction: Healthcare Associated Infections (HAI) are associated with increased cost, morbidit... more Introduction: Healthcare Associated Infections (HAI) are associated with increased cost, morbidity, and mortality. Risk factors for HAI are well established; however, the independent risk associated with an exaggerated inflammatory response has not been adequately studied. Hypothesis: The objective was to investigate baseline cytokine levels (IL-6, IL-10), their polymorphisms (RS1800795, RS1800896) and environment on the development of new HAI in ICU patients admitted with sepsis. Methods: This prospective observational study evaluated 78 patients admitted to ICU with early sepsis ( Results: Seventeen HAI were identified. The final regression model included APACHE II, invasive device score, antibiotics prior to ICU, and IL6 RS1800795. Based on the multivariate model, for every 1-point increase in APACHE II score there was a 3.4% increased risk for developing HAI. Cumulative invasive device score and early antibiotic use reduced the risk of HAI. In the univariate model, the presence ...
BackgroundIn hospitalized patients with COVID-19 pneumonia, progression to acute respiratory fail... more BackgroundIn hospitalized patients with COVID-19 pneumonia, progression to acute respiratory failure requiring invasive mechanical ventilation (MV) is associated with significant morbidity and mortality. Severe dysregulated systemic inflammation is the putative mechanism. We hypothesize that early prolonged methylprednisolone (MP) treatment could accelerate disease resolution, decreasing the need for ICU and mortality.MethodsWe conducted a multicenter, observational study to explore the association between exposure to prolonged, low-dose, MP treatment and need for ICU referral, intubation or death within 28 days (composite primary endpoint) in patients with severe COVID-19 pneumonia admitted to Italian respiratory high-dependency units. Secondary outcomes were invasive MV-free days and changes in C-reactive protein (CRP) levels.ResultsFindings are reported as MP (n=83) vs. control (n=90). The composite primary endpoint was met by 19 vs. 40 [adjusted hazard ratio (HR) 0.41; 95% confi...
Background: Central lineYassociated bloodstream infection (CLABSI) prevention efforts have increa... more Background: Central lineYassociated bloodstream infection (CLABSI) prevention efforts have increased over the past decade because of implications of the Affordable Care Act and mandatory reporting laws. These legislative measures allow for reduced reimbursement to hospitals with high level of CLABSIs and other health careYassociated infections. Objective: The aim of this study was to explore the impact of legislation and mandatory reporting on CLABSI rates and reporting. Methods: The study team performed a retrospective review of medical intensive care unit patients in January 2008, 2012, and 2015 to examine changes in CLABSI reporting by 2 methods (International Classification of Diseases [ICD] by providers and Centers for Disease Control by infection prevention [IP]), as well as changes in central line use over time. Data were summarized and compared. Percent agreement and. statistics were calculated for ICD-and IP-coded CLABSIs. Results: Among 465 intensive care unit patients, most were white (89.9%), males (52.0%), aged 58.7 T 17.1 years. Only 3 new CLABSIs were reported during the study period: 2 by ICD and IP in 2008, 1 by ICD in 2012, and 0 by either method in 2015. The percent agreement CLABSI Reporting
Background: Hospital mortality rates related to sepsis have decreased over the last decade, incre... more Background: Hospital mortality rates related to sepsis have decreased over the last decade, increasing the number of survivors of sepsis who may experience long-term consequences. Yet, little is known about how they perceive their illness experience and its aftermath. Objective: This study explores the experiences of sepsis survivors after 1 year of their index intensive care unit (ICU) stay. Methods: This phenomenological study was guided by Merleau-Ponty's philosophy. Participants were adult patients admitted directly to the medical ICU with sepsis who had an ICU stay of at least 48 hours and had been discharged from their index ICU stay for at least 1 year. Participants were invited by letter to participate in face-to-face or telephone interviews and a brief survey. Interviews were audio recorded, transcribed verbatim, and verified. An interpretive group read transcripts aloud to increase rigor of identifying meaning units, existential grounds, and thematic structure. Results: Eight participants were recruited over 20 months. Participants were primarily white (87.5%) females (75%) with an age range of 37 to 74 years who were interviewed between 1 and 2 years following an index sepsis ICU stay. Five major themes emerged from the transcripts: (1) how they survived, (2) blurring of time versus counting time by events, (3) helpful help versus unhelpful help, (4) powerless versus striving for control, and (5) survivor but not fully recovered. Discussion: Findings reflected a long trajectory of chronic illness in which the index episode of sepsis was not necessarily what stood out as figural to participants. The meaning of participant experiences must be considered in the context of a health care system that offers little to no systematic follow-up care after sepsis and little prevention. Participants expressed a need for advocacy and follow-up support.
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Papers by Reba Umberger