AACN Advanced Critical Care最新文献

Diabetes-related gastroparesis is a challenging complication of diabetes that often results in flares of intractable vomiting and recurrent hospitalizations. Currently, there is no standard of care or guidelines for the management of diabetes-related gastroparesis in the acute care setting, leading to inconsistent and suboptimal care for these patients. Consequently, patients with diabetes-related gastroparesis may have prolonged inpatient lengths of stay and frequent readmissions affecting their overall health and well-being. Successful management of diabetes-related gastroparesis requires a coordinated multimodal approach to address the different components of an acute flare, including nausea and vomiting, pain, constipation, nutrition, and dysglycemia. This case report demonstrates how the development and implementation of an acute care diabetes-related gastroparesis treatment protocol demonstrates efficacy and promise for better quality of care for this population.

Steroid-induced hyperglycemia was diagnosed in an older hospitalized patient after he was treated with the intermediate-acting glucocorticoid methylprednisolone. Before hospital admission, the patient did not have a diagnosis of diabetes. His elevated admission glucose level of 167 mg/dL along with his significant hyperglycemia after glucocorticoid initiation prompted the medical team to obtain a hemoglobin A1c result, 8.4%, which confirmed the diagnosis of type 2 diabetes. The capillary blood glucose level was elevated into the 200 to 399 mg/dL range for most of the patient's hospital stay while he was receiving subcutaneous insulin therapy of glargine and aspart correction and prandial bolus dosing. When the patient's subcutaneous insulin therapy was changed from glargine to neutral protamine Hagedorn insulin, the target glucose level range of 140 to 180 mg/dL was attained. From this case report, we determined that it is important to consider modifying subcutaneous insulin therapy by using another type of insulin when target glucose values are not achieved during the treatment of steroid-induced hyperglycemia.

Objective: To reduce the incidence of medical device-related pressure injuries associated with tracheostomies performed with the percutaneous dilation technique using a standardized multidisciplinary intervention.

Methods: The intervention was developed using the Agency for Healthcare Research and Quality Preventing Pressure Injuries Toolkit. A fenestrated polyurethane foam dressing was sutured in place under the tracheostomy flange during insertion to reduce the risk of medical device-related pressure injuries. The sutures were removed in pairs over a period of 7 to 10 days.

Results: Comparison of data from 2018 to 2021 demonstrated a decrease in the incidence of tracheostomy medical device-related pressure injuries from 13% to 0% in the first year, which was maintained for the following 3 years. This improvement was supported by electronic medical record audits, daily interdisciplinary rounds, weekly practice assessments, and primary nurse evaluations.

Conclusion: Implementation of a standardized process, supported by an interdisciplinary clinical team, can reduce medical device-related pressure injuries among patients undergoing percutaneous dilation tracheostomy.

As clinical leaders, advanced practice registered nurses are often called upon to respond to crises. Although frameworks for emergency preparedness and response have been established by the National Organization of Nurse Practitioner Faculties and the International Council of Nurses, the advanced practice registered nurse community is not consistently prepared to participate in crisis response. Merging of the previously established frameworks allows identification of additional opportunities for advanced practice registered nurses to be educated and engaged in emergency preparedness and all-hazards response, including preparation activities, communication, safety and security, incident management, assessment, intervention, and recovery. Additional areas of focus are leadership, ethics, and end-of-life care. Use of the existing frameworks combined with the lessons learned from the COVID-19 response can empower advanced practice registered nurses to improve their readiness to respond to future crises.

US military medical units have responded to natural disasters (eg, hurricanes, earthquakes), relieved overwhelmed civilian health care systems (eg, during the COVID-19 pandemic), and provided support to stabilization efforts after civil unrest. The military will continue to assist civilian agencies with future medical response to similar disasters, contagious outbreaks, or even terrorist attacks. The keys to an effective disaster response are unity of effort, prior coordination, and iterative practice during military-civilian exercises to identify strengths and areas of improvement. Critical care advanced practice nurses are likely to work concurrently with military medical colleagues in multiple scenarios in the future; therefore, it is important for these nurses to understand the capacities and limitations of military medical assets. This article describes the capabilities and collaboration needed between civilian and military medical assets during a variety of disaster scenarios.