Key insights on optimizing the nurses' roles and scope of practice during care transitions included having nurses provide "warm hand-offs" and serve as the "go-to person." The panel also identified current challenges to optimizing the nurses' roles and scope of practice across care transition points. Future research is required to determine effective nurse-led intervention components and in which context do they work or do not.

This article reports results from a systematic review used to inform the development of a best practice guideline to assist nurses in understanding their roles and responsibilities in promoting safe and effective client care transitions. A care transition is a set of actions designed to ensure safe and effective coordination and continuity of care as clients experience a change in health status, care needs, health care providers, or location.

Aim: The aim of this paper is to highlight evidence and key nursing practice, education, organization and policy recommendations from the original and revised Registered Nurses' Association of Ontario Best Practice Guideline, Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease (COPD). This paper introduces the notion of dyspnea as the sixth vital sign and presents evidence from the RNAO Best Practice Guideline and other relevant literature to support and enhance nursing care of dyspnea in clients with COPD.Background: COPD is an increasingly serious health issue. Nurses have significant opportunity to positively influence client outcomes and quality of life by assessing dyspnea, identifying problems, and applying appropriate evidence-based interventions. Best practice guidelines developed by the RNAO provide a framework to enhance nursing practice and client care.Design: A panel of nurses was assembled for the initial development of the guideline and more recently, the revision to the original guideline.Method: A structured evidence review based on the scope of the original guideline and supported by three clinical questions was conducted to capture the relevant literature and guidelines published since the original publication.Results: As a result of this work recommendations for nursing practice and education are discussed. Organizational and policy recommendations are also outlined. Conclusions:Nurses have opportunity to positively influence client outcomes and quality of life by assessing dyspnea, identifying problems, and applying appropriate evidence-based interventions.Relevance to Clinical Practice: Recommendations made in the best practice guideline will enhance nursing care of dyspnea in clients with COPD and dyspnea should be recognized as the sixth vital sign in individuals with COPD.

MIdazolam has been shown to interact synergistically with propofol during "co.induction" of anaesthesia. I However, it is uncertain whether mldazolam affects propofol requirements during, and recovery times following, total Intravenous anaesthesia (TIVA) In Day Care patients. A double-blind study was therefore designed to determine these effects. Here, we deacdbe unexpected cases of awareness with recall In our study population. METHODS: Ninety unpremedlcated ASA Class I and II adult Day Care patients, 'scheduled to undergo either knee erthreacepy or laparoscoplc procedures, gave written consent to the protocol approved by the hospital REB. Patients received, in a random fashion, either placebo (Group PLAC) or midazolam at a dose of 0.015 ms-ks "~ (Group MID-15), 0.030 mg.kg "~ (Group MID.30) or 0.045 rag.ks "~ (Group MID-45) prior to Induction of anaesthesia. Anaesthesia was then Induced with propofol 0.8-1.5 rag.ks "1 an.d alfantanil 20 Fg.kg "l, and alracurlum 0.5 mg.kg "1 to facilitate tracheal Intubatlon. Anaesthesia was malntalnad with a continuous Infusion of propofol beginning at 100 p.g.kg't.min "t, titrated as required to maintain HR and SBP within =2.0% of the patient's normal values, or in response to patient movement, while atfentanll was Infused st 0.5 Fg.kg'l.mln "~ (constant). Times to awakening ware compared postoperatively. In addition, a follow-up questionnaire, designed to evaluate the overall quality of the anaesthetic experience, was completed for each patient on the first post-operative day. Data were analyzed using the Chlsquare statistic and Flscher's Exact test where appropriate, with significance assumed when P<0.05 RESULTS: Propofol Infusion requirements varied significantly from one patient to another (range 80-280 ug.kg't.min'l), but cumulative requirements were not different between groups~ Rapid awakening was observed in all four groups (5=3, 4=2, 6==3 and 6• rain for groups PLAC, M-15, M-30 andM-45, respaotively). Unexpectedly, however, six patients experienced awareness with recall using this technique (4 of 23 patients in the PLAC group compared with 2 of 67 patients in the mldezolam treatment groups, P<0.02, Table). Five of the 6 patients experienced mild or moderate pain with their re(all, but no patient described any psychologlcat distress or anxiety, In fact, despite their ~perlence of awareness, 3 of the 6 patients related the quality of this anaesthetic to heve been superior to their last anasst hotic, For ethical reasons, the study was stopped. DISCUSSION: Despite the high quality of recovery, TIVA was associated with an unacceptably high incidence of awareness with recall In this study. This may have been due, In part, to the relatively low initial infusion rate of propofoL We unexpectedly found that low dose mldazolam (0.015-0,045 rag.ks "t) reduces the likelihood of intraoperative awareness, without prolonging recovery times REFERENCE: