Critical care nurse最新文献

Background: Early postpyloric feeding provides effective and safe enteral nutrition for patients with large hemispheric infarction receiving therapeutic hypothermia.

Local problem: Patients with large hemispheric infarction undergoing therapeutic hypothermia often have gastrointestinal dysfunction and undergo repeated bedside attempts at blind postpyloric feeding tube placement. Confirming tube position via radiography can delay nutrient intake, increase costs, and expose patients to unnecessary radiation.

Methods: In this quality improvement study, specialist nurses were trained to use ultrasonography instead of radiography to confirm postpyloric feeding tube position, reducing reliance on ancillary services. Preimplementation and postimplementation data included time from tube placement to first feeding and the frequency of radiography use. Surveys were conducted to assess the health care team's satisfaction with the new process.

Results: Sixty-seven placements (30 before implementation, 37 after implementation) were evaluated. Feeding start times significantly decreased by 34.85% (mean [SD], 741.20 [192.73] minutes before implementation vs 482.86 [166.15] minutes after implementation; P < .001). The addition of ultrasound guidance for postpyloric feeding tube placement significantly decreased the number of abdominal radiographs per patient by 56.0% (mean [SD], 2.5 [0.9] before implementation vs 1.1 [0.4] after implementation; P < .001). Most health care team members indicated that this practice change reduced the time to initiation of enteral nutrition for patients with large hemispheric infarction receiving therapeutic hypothermia.

Conclusions: By improving processes, we reduced feeding start times, minimized radiography use, and enhanced the health care team's satisfaction with postpyloric feeding tube placement for patients receiving therapeutic hypothermia.

Background: Central line [catheter]-associated bloodstream infection (CLABSI) is associated with longer stays and increased cost, morbidity, and mortality.

Local problem: An academic cardiothoracic intensive care unit had a high CLABSI incidence (standardized infection ratio of 2.3 at baseline). The hospital's executive leadership team (chief nursing officer, chief medical officer, and chief of quality and performance improvement) directed intensive care unit leaders to reduce the standardized infection ratio.

Methods: Interprofessional CLABSI reduction efforts were formulated using A3 methods based on the plan-do-check-act cycle. Unit leaders (nurses, physicians, advanced practice providers, and allied health professionals) met every 2 weeks for 2 years to formulate CLABSI reduction efforts. Efficacy of CLABSI reduction was evaluated with the standardized infection ratio.

Interventions: Quality improvement activities included improved hand hygiene compliance, optimization of central venous catheter insertion, improved chlorhexidine dressing adherence, daily assessment of high-risk catheters for removal, use of an electronic intensive care unit bundle checklist to highlight central venous catheter duration for clinicians, and promotion of a blood culturing stewardship program with guidance on when to obtain blood samples for culture.

Results: Interprofessional CLABSI reduction efforts reduced the standardized infection ratio from 2.3 to 0.8 over 3 years. The standardized utilization ratio, reflecting observed to expected central venous catheter days, decreased from 1.0 to 0.89.

Conclusion: Interprofessional CLABSI reduction efforts can be effective in a cardiac surgical intensive care unit and improve patient safety. Keys to success include teamwork, accountability, acceptance from intensive care unit staff, and support from hospital executive leaders.

Background: Surrogate decision-makers frequently experience negative emotional and physical outcomes due to their decision-making role in the adult intensive care unit. These negative outcomes may be mitigated by high-quality communication, but for this type of communication to occur, surrogate decision-makers must have trust in health care professionals.

Objective: To explore what is known about surrogate decision-makers' trust in health care professionals in the adult intensive care unit setting.

Methods: In this scoping review, CINAHL, APA PsycArticles, APA PsycInfo, MEDLINE, the Cochrane Library, the Web of Science, and Google Scholar were searched from inception to March 9, 2024.

Results: A total of 64 articles met the inclusion criteria. Surrogate decision-makers step into their decision-making role with a baseline level of trust in health care professionals, which is then modified by those professionals' behaviors such as technical competence, communication, honesty, benevolence, and interpersonal skills. The surrogate decision-maker's level of trust in health care professionals affects the surrogate's decision-making and behavior in the intensive care unit. A high-quality instrument is needed to measure surrogate decision-maker trust in health care professionals in the adult intensive care unit setting so that future research can focus on validating various trust-building interventions in this population.

Conclusion: Bedside staff members should incorporate the currently available research findings about building trust with surrogate decision-makers into their professional practice. Future research should focus on the development, validation, and dissemination of a new instrument designed specifically to measure surrogate decision-maker trust in health care professionals.

Background: Patients with critical illness often seek meaningful relationships with members of their care teams. The patient experience can be enhanced through a goals-of-care conversation, an aspect of palliative care that focuses on the patient-clinician relationship. Despite recommendations for early palliative care interventions, no standardized time for generalists to initiate palliative care interventions in the acute care setting has been established.

Local problem: An academic hospital identified a need for earlier palliative care interventions for patients admitted to the medical intensive care unit. The aim of this quality improvement project was to improve early palliative care interventions in the intensive care unit by increasing numbers of documented surrogate decision-makers and goals-of-care conversations. Newman's theory of health as expanding consciousness was used as a guide to improve the patient-clinician relationship through communication, early establishment of goals of care, and development of patient-centered care.

Methods: Recently admitted patients were screened during interprofessional team huddles with a modified surprise question ("Would you be surprised if this patient died during this hospitalization?") to identify those who might benefit from an early goals-of-care conversation. The preimplementation group included all admitted patients and the postimplementation group included only patients with a "no" on the surprise question.

Results: Analysis included 174 patients (139 before implementation, 35 after implementation). In the preimplementation group, 99 patients (71%) had documented surrogate decision-makers and 26 (19%) had documented goals-of-care conversations. In the postimplementation group, 34 patients (97%) had documented surrogate decision-makers and 14 (40%) had documented goals-of-care conversations.

Conclusion: Patients screened with the modified surprise question upon admission to the intensive care unit received earlier palliative care interventions, enhancing patient-centered care.

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.