Critical care nurse最新文献

Background: Catheter-associated urinary tract infections are among the most prevalent and costly types of hospital-acquired infections. During the COVID-19 pandemic, growing numbers of critical care patients required indwelling urinary catheters, leading to higher infection rates.

Local problem: A critical care unit saw a 7-fold increase in the rate of catheter-associated urinary tract infection during the COVID-19 pandemic. A review of procedures showed that the current standard of care for preventing such infections was inadequate. In particular, patients who could not have indwelling urinary catheters promptly removed risked a potential false-positive diagnosis of catheter-associated urinary tract infection due to clinicians' use of long-term catheters to obtain urine specimens for microbiological evaluation.

Methods: A literature review was performed to gather evidence on best practices for urine specimen collection in the critical care unit. An interprofessional task force including frontline nurses advocated implementation of a pilot project in 2 critical care units involving exchange of catheters before obtaining urine specimens for microbiological evaluation in any patient who had an indwelling catheter in place for more than 24 hours.

Results: Implementation of the new protocol resulted in a major reduction in the diagnosis of catheter-associated urinary tract infection, with no incidents occurring for 2 consecutive quarters. Based on these results, the new evidence-based workflow was incorporated as the standard of care for all adult inpatients.

Conclusion: Catheter exchange before collection of urine specimens in patients requiring urine culture evaluation can improve accuracy of diagnosis of catheter-associated urinary tract infection and promote antibiotic stewardship.

Background: In critically ill patients, intravenous fluid resuscitation is contentious. Although research has explored intravenous fluids for patients with sepsis or septic shock, evidence guiding fluid choices for trauma patients in intensive care units remains scarce.

Objective: To summarize current recommendations for intravenous fluid choices for resuscitation and their impact on outcomes in trauma patients in intensive care units.

Methods: The literature was appraised with a scoping review using the Joanna Briggs Institute framework.

Results: A search of databases (CINAHL Plus, MEDLINE, Health Source: Nursing/Academic Edition, PubMed, and Scopus) yielded 10 articles examining crystalloid and colloid solutions. In trauma patients, major adverse outcomes (mortality, acute kidney injury, hospital/intensive care unit length of stay) did not significantly differ according to crystalloid solution type except in patients with traumatic brain injury, for whom normal saline was beneficial. Albumin and hypertonic saline as adjuncts to fluid therapy were generally safe except for patients with traumatic brain injury.

Discussion: Balanced crystalloid solutions and normal saline can be used interchangeably in trauma patients except those with traumatic brain injury. The use of albumin for first-line resuscitation is questionable due to cost and lack of benefit over other fluids. Hypertonic saline may benefit patients with delayed abdominal closure after exploratory laparotomy.

Conclusion: In trauma patients, outcomes are not influenced by intravenous fluid type except for those with traumatic brain injury, for whom normal saline is preferred over balanced crystalloid solutions. Hypertonic saline and albumin may be adjunct therapies after considering cost, availability, and individual patient characteristics.

Background: Alcohol use disorder in the United States is increasing. Alcohol is the second most commonly abused drug worldwide, resulting in acute hospitalizations related to alcohol use and alcohol withdrawal syndrome. Management of alcohol withdrawal syndrome relies on screening tools to determine the need for treatment. The most commonly used tool is the Clinical Institute Withdrawal Assessment for Alcohol Scale-Revised (CIWA-Ar), which has not been validated for use in critical care units.

Objective: To evaluate whether the modified Minnesota Detoxification Scale (mMINDS) is more effective than the CIWA-Ar for evaluating acute withdrawal symptoms in patients in intensive care units.

Methods: This integrative review used the framework of Whittemore and Knafl. The literature was searched for studies related to mMINDS, neurocritical care, and critical care.

Results: Nine articles were included in the review. The review revealed 3 outcomes: nurses preferred the mMINDS over the CIWA-Ar, assessments with the mMINDS tool was more accurate for patients with CIWA-Ar scores greater than 10, and patient outcomes were improved with use of the mMINDS. The mMINDS is preferred over the CIWA-Ar for managing alcohol withdrawal syndrome in patients in intensive care units because it is associated with shorter stays, less benzodiazepine use, and a decrease in delirium tremens.

Conclusion: The findings regarding mMINDS can apply to both critical care and non-critical care settings. The mMINDS is preferred by nurses and results in more positive patient outcomes. The mMINDS is effective and should be used in critical care areas.

Background: Patient and family satisfaction with care in intensive care units is not reflected in Hospital Consumer Assessment of Healthcare Providers and Systems surveys. Gaps may be unknown.

Local problem: In a cardiothoracic intensive care unit, patient satisfaction scores were not assessed and gaps could not be addressed. The primary aim was to obtain baseline data on patient and family satisfaction. The secondary aim was to improve identified gaps in satisfaction.

Methods: A preintervention-postintervention, 2-cycle quality improvement project and a 12-month sustainability assessment were conducted to evaluate patient and family satisfaction in a cardiothoracic intensive care unit in a large academic health system from August 2022 to August 2023. The Nursing Intensive Care Satisfaction Scale was used to measure patients' satisfaction and the European Quality Questionnaire was used to measure family members' satisfaction with intensive care unit nursing care. Standardized scripting, processes for patient and family engagement during rounds, and structured communication were used to enhance patient and family engagement.

Results: At baseline (47 patients, 35 family members), overall patient and family satisfaction was high (mean [SD] satisfaction scores: patients, 87.6 [19.3]; family members, 94.6 [9.7]; P = .06). After intervention cycle 2, family members (n = 50) had high mean satisfaction scores on the Information Needs sub-scale of the European Quality Questionnaire. Family participation in rounds improved from 18.5% of rounds at baseline to 76.5% after intervention cycle 2 and was 61.5% at 12 months.

Conclusion: Strategies that engage family members in rounds improve communication and satisfaction.

Introduction: Prone ventilation is a standard treatment for acute respiratory distress syndrome, and its clinical benefits are well established. However, implementing prone positioning safely and effectively is challenging in patients who are pregnant, have intra-abdominal hypertension, or are in other high-risk groups.

Clinical findings and diagnosis: A patient in the third trimester of pregnancy (28 weeks and 6 days of gestation) developed a body temperature of 39 °C and severe respiratory distress. She was transferred to the intensive care unit, received noninvasive ventilation, and ultimately underwent endotracheal intubation. Because her oxygenation index remained below 100, she received a diagnosis of severe acute respiratory distress syndrome.

Interventions: The patient was safely placed in the prone position with a swim ring while receiving venovenous extracorporeal membrane oxygenation. During this period, her intra-abdominal pressure did not increase significantly.

Outcomes: The fetus was delivered by cesarean birth, and the patient was transferred to the general ward after extubation.

Conclusion: This case report describes the use of prone positioning in a pregnant patient. The report offers critical care nurses insights into the clinical management of patients who are pregnant or have intra-abdominal hypertension.

Background: Hospital-acquired pressure injuries are a significant patient safety concern. The Centers for Medicare & Medicaid Services tracks hospital-acquired pressure injuries as a patient safety indicator. Health care organizations with higher-than-expected rates may incur penalties.

Local problem: The pressure injury prevalence rate in a cardiothoracic intensive care unit was above the National Database of Nursing Quality Indicators benchmark. The current standard of care-use of the Braden scale for pressure injury risk assessment and the SKIN (surface, keep turning, incontinence care, and nutrition) care bundle-may not adequately address the needs of the intensive care unit population. In addition, cardiac patients present a special challenge because of their disease process and the mechanical support devices used to treat patients in cardiogenic shock, which place them at risk for the development of hospital-acquired pressure injuries.

Methods: A performance improvement project was carried out in the cardiothoracic intensive care unit to reduce the prevalence and incidence of hospital-acquired pressure injuries. A preintervention convenience cohort was compared with a postintervention cohort. The intervention consisted of use of the Cubbin-Jackson scale, an intensive care unit-specific risk-assessment tool, with linked interventions to prevent pressure injuries.

Results: The preintervention and postintervention cohorts consisted of 102 patients each. The pressure injury prevalence and incidence rates decreased by 67.84% and 36.43%, respectively, from before to after the intervention.

Conclusion: The use of an intensive care unit-specific risk-assessment tool with linked interventions to prevent pressure injury can help reduce hospital-acquired pressure injuries in an intensive care unit.