Critical care nurse最新文献

Background: Preventing hospital-acquired conditions is paramount to patient safety. Critically ill children are highly susceptible to hospital-acquired harm.

Local problem: To prevent hospital-acquired conditions, the pediatric intensive care unit at a quaternary care center implemented a novel interprofessional high-risk rounding program to improve unit work culture and address increased hospital-acquired condition rates before and during the COVID-19 pandemic.

Methods: Patients at greatest risk for selected hospital-acquired conditions were identified for the high-risk rounding program. This program offered rounds with scripted questions about elements of hospital-acquired conditions followed by education and/or acquisition of needed resources. Primary quality improvement outcomes were overall preimplementation and postimplementation rates of the following hospital-acquired conditions: central line [catheter]-associated bloodstream infection, catheter-associated urinary tract infection, unplanned extubation, and pressure injury. Sustainability of the project was also evaluated.

Results: Over 2 years, 624 rounds for 488 unique patients were conducted. Rounds resulted in 351 interventions, including escalation of concerns, direct patient care, resource procurement, and education. Patients who received high-risk rounds were less likely than those who did not receive rounds to incur a hospital-acquired condition. A χ2 test of association revealed a significant negative association between hospital-acquired conditions and receipt of high-risk rounds (χ2 = 22.5, P < .001). The mean rate of project hospital-acquired conditions decreased from 5.41 to 2.89 events per 1000 patient days following detection of special cause variation. High-risk rounds prevented an estimated 50 hospital-acquired conditions during the project period.

Conclusion: Implementation of high-risk rounds reduced the rate of project-specific hospital-acquired conditions by 46.5%, which was sustained over the 2-year project period.

Background: Electrolyte abnormalities occur often in critically ill patients with cancer. Correction of these abnormalities improves patient outcomes. Administration of intravenous electrolytes is associated with risks. Order sets have been implemented to improve standardization, timeliness of administration, and patient safety.

Local problem: At a large academic cancer center, a nurse-driven central venous catheter intravenous electrolyte replacement order set was available in the intensive care unit, but adherence and barriers to use had not been assessed. The purpose of this quality improvement project was to define the baseline adherence rate to the electrolyte replacement order set.

Methods: A retrospective medical record review was conducted of medical intensive care unit patients with an active intravenous electrolyte replacement order set. All intravenous electrolytes administered within the first 72 hours of the intensive care unit stay were assessed for order set adherence.

Results: The order set adherence rate was 78.5%. The mean turnaround time from laboratory result to electrolyte administration was 3.1 hours. Deviations were predominantly characterized by administration of a lower electrolyte dose than indicated by the order set and administration of the incorrect electrolyte salt form.

Conclusion: The intensive care unit intravenous order set adherence rate revealed issues with administration of potassium, magnesium, and phosphate. In response, the interprofessional intensive care unit team implemented an electronic health record feature that displays the most recent electrolyte laboratory result for nurse review before electrolyte administration.

Background: The increased complexity of critical care nursing has resulted in nurses performing more high-risk, low-volume (HRLV) procedures, which may increase patient risk.

Local problem: The purpose of this project was to develop a resource for critical care nurses to more effectively manage HRLV scenarios at intensive care units at a large urban hospital to improve nurses' practice.

Methods: CINAHL and Medline databases were searched using the keywords high-risk low-volume, HRLV, badge buddy, just in time, and nurse competency. Twenty articles were identified, and 4 were included in this project. An accessible printed resource packet was created as a form of education and reference in HRLV scenarios. Each packet was laminated and kept at nurses' stations and included summaries, "pearls" (highlights), diagrams, checklists, and QR codes that linked directly to facility policies. Nurses were invited to complete an 8-question survey 8 weeks after implementation.

Results: Forty-three nurses completed the survey: 63% worked day shift, and 100% found the resource relevant. On average, the nurses agreed the packet increased knowledge, saved time, helped access policies, and influenced practice. On a scale of 1 to 10, the nurses rated the packet "very helpful" (mean, 9.09). When asked what was useful, participants indicated "easily accessible" and "finding information."

Conclusion: The resource packet has been used in HRLV scenarios and with new nurses during downtime. It was easy to implement and can be individualized for many units and patient populations. It serves as a bridge to easily bring best practice information to the bedside.

Background: Enteral feeding intolerance, a type of gastrointestinal dysfunction, is common in adults receiving mechanical ventilation, yet its definition and clinical assessment remain variable. If untreated, this syndrome may lead to underfeeding, which is associated with worse patient outcomes.

Objective: To describe what is known about enteral feeding intolerance, including who is at risk, clinical symptoms, identifying measures used, treatment, and clinical implications for nursing practice.

Results: Enteral feeding intolerance is identified by (1) changes in gastrointestinal function, (2) high gastric residual volume, and/or (3) inadequate delivery of enteral nutrition. A combination of gastrointestinal symptoms and high gastric residual volume is generally used to diagnose the condition. The most common symptoms are vomiting, abdominal distention, absence of bowel sounds or flatus, and diarrhea. Administration of promotility agents and reduction of the enteral formula rate are most often used to reduce the effects of enteral feeding intolerance until it resolves.

Discussion: Many gastrointestinal assessment findings are subjective and lack precision. Although the routine measurement of gastric residual volume is no longer standard practice, it is indicated in patients at risk for enteral feeding intolerance.

Conclusion: Nurses should become familiar with how to assess for and treat enteral feeding intolerance, as well as rule out other common gastrointestinal complications. Clinical biomarkers are needed to objectively identify enteral feeding intolerance in critically ill patients.

Introduction: Extracorporeal membrane oxygenation is a life-sustaining therapy that can produce complex ethical scenarios. Ethical challenges include patient selection and initiation, a frequently abbreviated informed consent process, ambiguity related to ongoing benefit and withdrawal of extracorporeal membrane oxygenation, resource intensity, and moral distress.

Clinical findings and diagnosis: A 50-year-old man with mucinous colorectal carcinoma was admitted to the hospital. He encountered treatment complications and received cannulation for extracorporeal membrane oxygenation twice during his stay. Ethical issues included the potentially limited physiological benefits of extracorporeal membrane oxygenation, fluctuations in his decision-making capacity, and need to ensure that decisions honored his preferences.

Interventions: A novel Values Balancing framework is used to identify and address ethical issues, possible courses of action, applicable values, open questions, other perspectives, and ethically supportable courses of action. With this framework, an action plan is established and the team is encouraged to review, reassess, and reflect on outcomes. The framework is applied to the case study.

Outcomes: The patient was transitioned to comfort care according to his wishes and died in the intensive care unit.

Conclusion: Using a structured framework to approach ethical challenges may facilitate decision-making and collaborative discussions that optimize ethical approaches to extracorporeal membrane oxygenation. Critical care nurses can assist with goals-of-care discussions, support families, and advocate for early involvement of bioethics and palliative support personnel to navigate ethical challenges.