Critical care nurse最新文献

Background: Iatrogenic malnutrition is a significant burden to patients, clinicians, and health care systems. Compared with well-nourished patients, underfed patients (those who receive less than 80% of their daily energy requirement) have more adverse outcomes related to nutritional status. Volume-based protocols allow for catch-up titrations, are consistently superior to rate-based protocols, and can be implemented in most settings.

Local problem: This project was conducted in an 8-bed neuroscience intensive care unit in which up to 41% of patients who required enteral feeding were underfed.

Methods: This quality improvement clinical practice change project used a before-and-after design to evaluate (1) the effect of implementing a volume-based feeding protocol on the delivery of enteral feeds and (2) the effect of a nutrition-based project on staff members' attitudes regarding nutrition in critical care. The effectiveness of a volume-based feeding titration protocol was compared with that of a rate-based feeding protocol for achieving delivery of at least 80% of prescribed nutrition per 24-hour period. Staff members' attitudes were assessed using a survey before and after the project.

Results: During 241 enteral feeding days (n = 40 patients), the percentage of delivered enteral feeding volume and the percentage of days patients received at least 80% of the prescribed volume increased after volume-based feeding was implemented. After project implementation, 74 staff members reported increased emphasis on nutrition delivery in their practice and a higher level of agreement that nutrition is a priority when caring for critically ill patients.

Conclusions: Using a volume-based feeding protocol with supplemental staff education resulted in improved delivery of prescribed enteral feeding.

Background: The COVID-19 pandemic resulted in unprecedented health care challenges and transformation of nursing practice. A significant challenge faced by health care systems was the rapid identification and training of nurses in various specialties, including critical care, to care for a large influx of critically ill patients.

Objective: To identify common themes and modalities that support best practices for the rapid training of registered nurses in team-based critical care nursing.

Methods: With the Whittemore and Knafl integrative review methodology as a framework, a literature review was conducted using a priori search terms.

Results: The integrative review included 11 articles and revealed 3 common themes: communication challenges, team dynamics, and the methodological approach to implementing training.

Discussion: This integrative review highlighted 3 main implications for future practice and policy in the event of another pandemic. Clear and frequent communication, multidisciplinary huddles, and open communication are paramount for mitigating role confusion and enhancing team dynamics. A multimodal approach to training appears to be feasible and effective for rapidly training support registered nurses to care for critically ill patients. However, the optimal training duration remains unidentified.

Conclusions: Rapidly training registered nurses to care for critically ill patients in a team-based dynamic is a safe and effective course of action to mitigate staff shortages if another pandemic occurs.

Background: Patients with anemia have poorer outcomes following cardiac surgery than do those without anemia. To improve outcomes, the Enhanced Recovery After Surgery cardiac recommendations include optimizing patients' condition, including treating anemia, before surgery.

Local problem: Despite implementing Enhanced Recovery After Surgery initiatives, a midwestern cardiothoracic surgery group recognized a care gap in preoperative patients with anemia. No standardized protocol was in use.

Methods: An anemia optimization protocol was developed for perioperative care of patients with anemia. Data from retrospective medical record review were analyzed to determine relationships between protocol use and secondary outcomes. The protocol was created using best evidence and expert consensus. Cardiac surgery and hematology specialists revised the protocol and agreed on a final version. The protocol was integrated into the consultation process for cardiac surgery patients.

Results: During the implementation period, 23 of 55 patients with anemia (42%) received interventions via the anemia optimization protocol. The mean quantity of packed red blood cells transfused perioperatively per patient was 1.9 U in the protocol group and 3.5 U in the nonprotocol group. In the subgroup of patients experiencing postoperative acute kidney injury, the mean increase in creatinine level was 0.65 mg/dL in the protocol group and 1.52 mg/dL in the nonprotocol group. Four patients in the protocol group (17%) and 6 patients in the nonprotocol group (19%) experienced postoperative acute kidney injury.

Conclusion: Preoperative anemia is associated with poorer cardiac surgical outcomes. Incorporating the anemia optimization protocol into practice may mitigate the risk of postoperative complications for patients with anemia. Continued use of the protocol is recommended.

Background: Patients admitted to the intensive care unit have complex medical problems and increased rates of mortality and recurrent hospitalization for the following 10 years compared with patients without a history of critical illness. Delayed access to palliative care can result in untreated symptoms, lack of understanding of care preferences, and preventable admissions. Despite studies supporting palliative care screening, there is no standardized method to assess palliative care needs of patients admitted to critical care units.

Local problem: A community hospital critical care team identified a need for an improved palliative care process for patients admitted to the intensive care unit.

Methods: The aim of this quality improvement project was to improve patient access to timely palliative care consultation while increasing the reach of the palliative care team. Guided by the Institute for Healthcare Improvement model of plan-do-study-act cycles, the team created a palliative care screening tool with clinical indicators for nurses to use upon patient admission. Patients with numeric scores indicating positive screening tool results could be automatically referred for palliative care consultation.

Results: Of 267 patients, 59 (22%) had positive screening tool results, compared with 31 (11.6%) identified with the traditional consultative method. Descriptive analysis revealed that patients identified for referral without use of the screening tool were hospitalized a mean of 6 days until consultation was requested.

Conclusion: The screening process can maximize the benefit of palliative care services with early patient identification, improved consultation efficiency, decreased critical care resource use, and reduced readmission rates.

Introduction: Non-ventilator-associated hospital-acquired pneumonia is a preventable health care-associated infection accounting for 1 in 14 hospital deaths. Clinical factors influencing this condition include oral health and bacteria and oral care. This case report addresses diagnostics and clinical variables related to non-ventilator-associated hospital-acquired pneumonia and emphasizes the importance of prevention.

Clinical findings: A 90-year-old woman was admitted to the hospital with shortness of breath and generalized weakness from new-onset atrial fibrillation and suspected heart failure exacerbation. During the hospitalization, her oral health status declined and oral bacterial colonization shifted, with Neisseria becoming the most common oral bacterial genus around the time of development of probable non-ventilator-associated hospital-acquired pneumonia.

Diagnosis: The patient had new respiratory symptoms and a chest radiograph positive for pneumonia on day 4 and was subsequently diagnosed with probable non-ventilator-associated hospital-acquired pneumonia.

Interventions: Intravenous antibiotic treatment was initiated. Oral care was completed on only 2 of 7 days. The patient received limited ambulation assistance and encouragement from staff and family members. No dysphagia screening was documented.

Outcomes: On day 6, the patient was discharged with oral antibiotics to her independent living facility with home health care.

Conclusions: Consistent oral care, early and frequent physical activity, and measures aimed to reduce aspiration risk are key interventions for all hospitalized patients to prevent non-ventilator-associated hospital-acquired pneumonia. Further research is warranted to assess shifts in oral bacteria and general oral health during hospitalization, which could provide clinically meaningful data on risk for non-ventilator-associated hospital-acquired pneumonia.