Introduction β2 agonists have several properties that could be beneficial in acute lung injury (ALI). We therefore chose to study the effect of inhaled β2 agonist use (salbutamol) on duration and severity of ALI.

BackgroundThe complex process of discharging patients from acute care to community care requires a multifaceted interaction between all health care providers and patients. Poor communication in a patient’s discharge can result in post hospital adverse events, readmission, and mortality. Because of the gravity of these problems, discharge planning has been emphasized as a potential solution. The purpose of this paper is to identify communication barriers to effective discharge planning in an acute care unit of a tertiary care center and to suggest solutions to these barriers.MethodsHealth care providers provided comments to a single open-ended question: “What are the communication barriers between the different health care providers that limit an effective discharge of patients from Unit 36?” We conducted qualitative thematic analysis by identifying themes related to communication barriers affecting a successful discharge process.ResultsThree broad themes related to barriers to the discharge process were identified: communication, lack of role clarity and lack of resources. We also identified two themes for opportunities for improvement, ie, structure and function of the medical team and need for leadership.ConclusionWhile it was evident that poor communication was an overarching barrier identified by health care providers, other themes emerged. In an effort to increase inter-team communication, “bullet rounds”, a condensed form of discharge rounds, were introduced to the medical teaching unit and occurred on a daily basis between the multidisciplinary team. To help facilitate provider-patient communication, electronic transfer of care summaries were suggested as a potential solution. To help role clarity, a discharge coordinator and/or liaison was suggested. Communication can be enhanced through use of electronic discharge summaries, bullet rounds, and implementation of a discharge coordinator(s). The findings from this study can be used to aid future researchers in devising appropriate discharging strategies that are focused around the patient and inter-health care provider communication.

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SummaryBackground: Frail older inpatients are at risk of unintended adverse events while in hospital, particularly falls, functional decline, delirium and incontinence. Objective: The aim of this pragmatic trial was to pilot and evaluate a multi-component knowledge translation intervention that incorporated a nurse-initiated computerized clinical decision support tool to reduce harms in the care of older medical inpatients. Methods: A stepped wedge trial design was conducted on six medical units at two hospitals in Calgary, Alberta, Canada. The primary quantitative outcome was the rate of order set use. Secondary outcomes included the number of falls, the average number of days in hospital, and the total number of consults ordered for each of orthopedics, geriatrics, psychiatry and physiotherapy. Qualitative analysis included interviews with nurses to explore barriers and facilitators around the implementation of the electronic decision support tool. Results:The estimated mean rate of order set use over a 2 week period was 3.1 (95% CI 1.9-5.3) sets higher after the intervention than before. The estimated odds of a fall happening on a unit over a 2-week period was 9.3 (p = 0.065) times higher before than after the intervention. There was no significant effect of the intervention on length of hospital stay (p = 0.67) or consults to related clinical services (all p <0.2). Interviews with front-line nurses and nurse managers/educators revealed that the order set is not being regularly ordered because its content is perceived as part of good nursing care and due to the high workload on these busy medical units. Conclusions: Although not statistically significant, a reduction in the number of falls as a result of the intervention was noted. Frontline users' engagement is crucial for the successful implementation of any decision support tool. New strategies of implementation will be evaluated before broad dissemination of this knowledge translation intervention.

234 ALI = acute lung injury; AQP = aquaporin; ARDS = acute respiratory distress syndrome; FiO 2 = fractional inspired concentration of oxygen; IL = interleukin; PaO 2 = partial pressure of oxygen; TNF-α = tumor necrosis factor alpha. Critical Care August 2004 Vol 8 No 4 Groshaus et al. IntroductionAcute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are important because of the continued high mortality and costs of care of these conditions. Beta adrenergic agonists are inexpensive and are actually often used in the treatment of patients who have ALI or ARDS for reasons not related to attempts to improve resolution of lung injury. For example, inhaled beta-2 adrenergic agonists are used to decrease airway resistance when it is increased in ALI and ARDS. Intravenously infused beta adrenergic agonists are used when the circulation requires inotropic support because of shock or ventricular dysfunction, both of which are common in ALI and ARDS. It is unknown whether beta adrenergic agonists used for these other reasons also improve the resolution of ALI.We have chosen to focus on the evidence that beta-2 adrenergic agonists act through three mechanisms (increased clearance of salt and water from alveoli, anti-inflammatory effects, and bronchodilation) to improve the pathophysiology, and possibly the rate and success of resolution, of pulmonary edema and ALI. This leads to the hypothesis that beta-2 adrenergic agonists may be beneficial therapy for patients with ALI or with ARDS. DefinitionsDifferent definitions and scoring systems have been developed since the "adult respiratory distress syndrome" was first described by Ashbaugh and colleagues in 12 patients in 1967 [1]. The most current consensus conference definition of ALI is acute onset of acute respiratory failure characterized by PaO 2 /FiO 2 ≤300 mmHg, bilateral infiltrates, and pulmonary capillary wedge pressure AbstractAcute lung injury (ALI) and the acute respiratory distress syndrome are complex syndromes because both inflammatory and coagulation cascades cause lung injury. Transport of salt and water, repair and remodeling of the lung, apoptosis, and necrosis are additional important mechanisms of injury. Alveolar edema is cleared by active transport of salt and water from the alveoli into the lung interstitium by complex cellular mechanisms. Beta-2 agonists act on the cellular mechanisms of pulmonary edema clearance as well as other pathways relevant to repair in ALI. Numerous studies suggest that the beneficial effects of beta-2 agonists in ALI include at least enhanced fluid clearance from the alveolar space, anti-inflammatory actions, and bronchodilation. The purposes of the present review are to consider the effects of beta agonists on three mechanisms of improvement of lung injury: edema clearance, anti-inflammatory effects, and bronchodilation. This update reviews specifically the evidence on the effects of beta-2 agonists in human ALI and in models of ALI. The available evidence suggests that beta-2 agonists may be efficacious t...