Critical care nurse最新文献

Background: After terminal extubation, more than 30% of patients experience a period of persistent dyspnea. Practices regarding terminal extubation at the end of life vary widely, and evidence for practice superiority is lacking. Critical care nurses are often tasked with making intervention decisions.

Local problem: At a 368-bed acute care hospital, nurses reported a lack of training on managing end-of-life symptoms associated with terminal extubation and the need for a standardized protocol to guide assessment and interventions. The aim of this study was to examine how use of an evidence-based terminal extubation protocol affects bedside nursing practice and clinician experience.

Methods: An interprofessional work group conducted a needs assessment, developed a terminal extubation protocol, provided education, and implemented the protocol. The protocol included the use of the Respiratory Distress Observation Scale as a new tool to evaluate patient distress and specified reassessment frequency, anticipated dose calculation, titration parameters, and steps for weaning. The work group examined the use of continuous infusion, bolus dosing, titration, and interventions before and after protocol implementation.

Results: Findings after protocol implementation included an increased reliance on bolus dosing and titration for evolving symptoms, greater use of evidence-based end-of-life medications, improved documentation demonstrating calculation of anticipatory doses, and an average time from start of process to extubation of approximately 21 minutes. Clinicians reported that use of the protocol improved symptom management.

Conclusion: A terminal extubation protocol can provide critical care nurses with an objective tool to guide assessment and interventions. Effective protocol implementation requires strong interprofessional collaboration.

Background: Women with large breasts are at risk for wounds after sternotomy.

Local problem: Over 12 months, 7 of 110 female patients who underwent sternotomy (6.4%) had 274 additional hospital days related to pressure injuries and sternal dehiscence after sternotomy. The financial burden for the longer stays was more than $751 000. The purpose of this quality improvement initiative was to implement a soft, comfortable bra to prevent wounds and sternal dehiscence in female patients after sternotomy.

Methods: Nurses implemented a new bra that reduced wound tension, had stretchable material that could expand for swelling, did not absorb moisture, and was available in a range of sizes to accommodate all women. Staff members measured patients' chest circumference before surgery and dressed patients in the bra in the operating room immediately after surgery. Patients wore the bra for breast support 20 to 24 hours a day for 6 weeks after surgery.

Results: The new bra was used for 82 patients. No patients who wore the bra developed sternal dehiscence or chest pressure wounds. The wound incidence rate decreased from 6.4% to 0%.

Conclusion: Female patients undergoing sternotomy should be dressed in a comfortable and appropriately sized bra immediately after surgery and should wear it for 6 weeks. Such a bra can help prevent sternal dehiscence and pressure injuries.

Background: Hospitalized patients often experience sleep disruption that fragments their sleep and disturbs their circadian rhythms, putting them at risk for sleep deprivation. The risk increases with greater severity of illness and is especially high in intensive care unit patients. Sleep deprivation can prolong the intensive care unit stay, contribute to emotional and physiological distress, and even increase the patient's risk of death.

Local problem: Critical care nurses in a 28-bed medical intensive care unit reported that patients often complained of sleep disruption or exhibited emotional and physical distress resulting from sleep deprivation. An analysis of the gap between recommended evidence-based best practice and current practices in the unit revealed numerous opportunities to improve patients' sleep. The aim of this evidence-based quality improvement project was to increase interprofessional adherence to an existing sleep-promoting schedule to reduce avoidable interruptions and improve patient sleep quality.

Methods: To promote sleep, staff member interactions with patients between midnight and 4 am were minimized, if appropriate. Documented patient encounters and call bell initiation were evaluated as process measures. Patients' self-perceived sleep quality, an outcome measure, was evaluated using the Richards-Campbell Sleep Questionnaire.

Results: Adherence to a sleep-promoting schedule reduced patient sleep interruptions between midnight and 4 am by as much as two-thirds while increasing patients' overall self-perceived sleep quality by 6.7 percentage points.

Conclusion: An interprofessional effort to minimize patient interruptions at night in an intensive care unit setting led to improved patient sleep quality and sustainable practice changes.

Background: Critically ill patients may have pressure injuries upon admission, increasing the need for nursing care and resources.

Local problem: An increase in pressure injuries during the COVID-19 pandemic required implementation of 2-nurse skin assessments for pressure injury identification and prevention.

Methods: A quality improvement initiative incorporating tele-intensive care unit (tele-ICU) nurses and wound, ostomy, and continence nurses using camera technology in collaboration with bedside intensive care unit nurses was conducted in 3 intensive care units within a multi-institutional health care system from 2021 through 2023. Sites included an academic medical center and 2 community hospitals. The team implemented the following bundle: (1) tele-ICU nurses provided second skin assessments, (2) tele-ICU and bedside intensive care unit nurses reviewed pressure injury prevention measures on admission, and (3) tele-ICU nurses documented pressure injuries. Customized daily dashboards and automated reporting were implemented. Crude data descriptive analysis and segmented regression analysis were used.

Results: For 4723 admissions, 2-nurse skin assessment compliance increased from 46.9% during the 9-month preimplementation period to 80.8% during the 18-month postimplementation period, showing that compliance increased by 72.3%. Overall, 1153 pressure injuries were identified on intensive care unit admission or transfer, a mean of 20.6 per month before implementation and 64.1 per month after implementation. In the segmented regression analysis, the number of pressure injuries identified as present on admission significantly increased after implementation (P = .02).

Conclusion: Integrating tele-ICU nurses, bedside intensive care unit nurses, and wound, ostomy, and continence nurses with camera technology increased compliance with 2-nurse assessments, leading to identification of present-on-admission pressure injuries, prompt treatment, and preventive interventions.