AACN Advanced Critical Care最新文献

In an increasingly complex health care environment, the prompt recognition of critical illnesses, such as cardiogenic shock, is imperative for improving patient outcomes. Telehealth services, such as the integration of virtual intensive care units, can facilitate collaboration between clinicians to expedite treatment of complex conditions. In this case report, an intensive care nurse practitioner's use of telehealth resulted in prompt diagnosis and treatment for a patient with cardiogenic shock. The patient was initially treated for presumed septic shock. The intensive care nurse practitioner suspected cardiogenic shock and consulted with an intensivist using a virtual intensive care model of care. The patient was treated for cardiogenic shock and has returned to his baseline status, despite the morbidity and mortality typically associated with cardiogenic shock. Integration of virtual intensive care units in other health systems can offer one way to improve outcomes for critically ill patients, especially those with low-frequency, high-risk conditions.

Interstitial lung disease is a complex radiographic and histologic diagnosis, encompassing more than 200 disorders. Acute exacerbation presents as acute respiratory failure and mimics an upper respiratory viral syndrome. An extensive diagnostic workup is required to rule out other causes of acute respiratory failure and identify potential triggers. Treatment, including general supportive care and immunosuppression, depends on the underlying pathology. Respiratory support with high-flow nasal cannula should be initiated early in an attempt to minimize progression to invasive mechanical ventilation. Multidisciplinary conversations are vital to establish a care plan and outline candidacy for invasive mechanical ventilation, extracorporeal life support, and transplantation.

Intravenous smart pump alarm fatigue remains a persistent and underrecognized patient safety concern in acute and critical care settings. Although alarm fatigue has been traditionally associated with physiological monitors, intravenous smart pumps are also a frequent source of alarms for hospitalized patients that contribute substantially to alarm fatigue. This article synthesizes current evidence on intravenous smart pumps and related alarm fatigue, identifies knowledge gaps, and proposes short-term and long-term interventions. Inconsistencies in alarm design and inadequate human-centered design have led to the development of intravenous smart pump systems that create an unacceptably high number of technical alarms that are unrelated to changes in patient status. Data-driven strategies are discussed as mechanisms to reduce burden and enhance alarm effectiveness. A systems-level approach combining human factors engineering, intelligent algorithm development, and clinical partnerships with manufacturers is essential for reducing alarm-related risk, decreasing nursing workload, and improving patient outcomes.

Secondary medication delivery using large-volume smart pumps offers important workflow and safety benefits. However, the widely used linear peristaltic large-volume smart pumps rely on sufficient head-height differential for accurate secondary infusion, leading to underdelivery risks. This article outlines common clinician workarounds used to mitigate these risks, including delivering secondary medications via primary mode, programming excess volume to be infused, clamping primary lines, and using short-set primary delivery. Although intended to ensure full medication delivery, these strategies introduce safety risks, increase alert burden, and heighten cognitive load. In contrast, cassette-based large-volume smart pumps use valve-controlled fluid delivery, eliminating the need for head-height differential and reducing the potential for human error. This review evaluates the risks and rewards of these workarounds and offers guidance to support informed decision-making while advocating for long-term technology solutions that improve safety, reduce clinician burden, and align with best practices in infusion therapy.

Diagnostic error is increasingly identified as a concern in health care. The purposes of this article are to provide an understanding of diagnostic error and its contributing factors and to briefly review strategies to reduce errors. A literature review provided a definition of diagnostic error, a synopsis of diagnostic error prevalence and settings, systemic and individual factors contributing to diagnostic error, and cognitive biases and errors in diagnostic reasoning. Strategies to address diagnostic error are discussed. Diagnostic errors are prevalent across clinical settings, may result in harm, and are preventable. Enhancing the education of health care professionals related to diagnostic reasoning and metacognition, using clinical decision-making tools, and advocating for strong communication practices may reduce diagnostic errors in practice settings.

Diagnostic error is a critical issue in health care. To reduce diagnostic error and enhance practice safety of new graduates, advanced practice registered nurse (APRN) learners need intentional preparation in diagnostic reasoning. It is imperative that APRN programs integrate diagnostic reasoning into all program curricula. This article provides an overview of teaching strategies aimed at promoting skill development in diagnostic reasoning, specifically related to knowledge development, differential diagnosis, and reflective practices. The article reviews foundational information related to dual-process thinking and teaching strategies for APRN primary and acute care curricula. Knowledge development is supported by illness scripting and problem representation activities. Skills in differential diagnosis and diagnosis prioritization are supported by the use of grids and lists. Cognitive debiasing and reflective practice are supported through self-explanation and structured reflection. Implementation of tailored teaching strategies can effectively prepare learners for clinical practice as diagnosticians.

Diagnostic errors are the most common cause of medical mistakes in the United States. Nurse practitioners (NPs) are critical in reducing the incidence of diagnostic errors, because diagnosis is a common competency for NPs. Although strategies for teaching diagnostic reasoning in NP education have been studied, little research has been conducted on evaluating diagnostic reasoning competencies among NP students. This integrative literature review was performed to identify and synthesize diagnostic reasoning competency assessment strategies in NP education. Data were evaluated for quality and synthesized to provide a comprehensive, actionable overview for NP educators. Although most assessments have been implemented among medical learners, most are also based on processes common to interprofessional diagnostic reasoning competencies. A small number were developed or implemented with NP learners. Current assessment methods may be used in NP education in various settings (eg, simulation education, clinical rotations) with varying reliability and validity.

Acute care nurse practitioners (ACNPs) provide care in a variety of settings and for a wide range of patient acuities. Flexible use of both analytic and nonanalytic thinking is necessary for safer and efficient diagnostic reasoning (DR). The purpose of this article is to review the diagnostic thought process required of ACNPs, provide a case-based example of DR in a complex secondary headache scenario, and identify key tools to help ACNP learners develop strong DR skills. Multiple strategies for developing or advancing DR competencies can be used by ACNP learners at all levels using learner-driven approaches. Statistically significant improvement in DR performance can be achieved with intentional, learner-driven activities and metacognitive exercises. ACNP learners have the opportunity to master DR using various system 1, system 2, and metacognitive processes to ensure safe and effective DR, even in the most complex of cases.