International critical care nursing considerations and quality indicators for the 2017 surviving sepsis campaign guidelines

An exploration of intensive care nurses' perceptions of workload in providing extracorporeal membrane oxygenation (ECMO) support: A descriptive qualitative study

BACKGROUND

There is increasing use of extracorporeal membrane oxygenation (ECMO) in intensive care, where nurses provide the majority of the required ongoing care of cannulas, circuit, and console. Limited evidence currently exists that details nursing perspectives, experiences, and challenges with workload in the provision of ECMO care.

OBJECTIVE

The objective of this study was to investigate intensive care nurses' perceptions of workload in providing specialist ECMO therapy and care in a high-volume ECMO centre.

METHODS

The study used a qualitative descriptive methodology through semistructured interviews. Data were analysed using an inductive thematic analysis approach following Braun and Clarke's iterative process. This study was conducted in an intensive care unit within an Australian public, quaternary, university-affiliated hospital, which provides specialist state-wide service for ECMO.

FINDINGS

Thirty ECMO-specialist trained intensive care nurses were interviewed. This study identified three key themes: (i) opportunity; (ii) knowledge and responsibilities; and (iii) systems and structures impacting on intensive care nurses' workload in providing ECMO supportive therapy.

CONCLUSIONS

Intensive care nurses require advanced clinical and critical thinking skills. Intensive care nurses are motivated and engaged to learn and acquire ECMO skills and competency as part of their ongoing professional development. Providing bedside ECMO management requires constant monitoring and surveillance from nurses to care for the one of the most critically unwell patient populations in the intensive care unit setting. As such, ECMO nursing services require a suitably trained and educated workforce of intensive care trained nurses. ECMO services provide clinical development opportunities for nurses, increase their scope of practice, and create advanced practice-specialist roles.

The Predictors of Perceived Barriers and Facilitators of Applying Sepsis Six Guidelines Among Critical Care Nurses

BACKGROUND

Sepsis is a life-threatening condition that demands quick and cautious interventions from nurses, as they are the frontline caregivers, so they are essential in recognizing early signs of sepsis, initiating prompt healthcare interventions, and providing comprehensive care to improve patient outcomes. This study aimed to examine the predictors of perceived barriers and facilitators of applying evidence-based sepsis guidelines among critical care nurses.

METHODS

This cross-sectional descriptive study was conducted on a convenience sample of 180 nurses working in critical care settings (ICU, critical care unit, ED, burning unit, dialysis unit) at a university hospital. A valid and reliable questionnaire was used to examine the predictors of perceived barriers and facilitators of applying evidence-based sepsis guidelines among critical care nurses.

RESULTS

This study revealed that the main barriers faced by critical care nurses are lack of sepsis recognition during observational rounds and delay in sepsis diagnosis by medical staff. For the most common facilitators of applying Sepsis Six guidelines, the participating nurses reported the presence of a written tool/protocol for sepsis identification and management.

CONCLUSIONS

The study emphasized the importance of the presence of evidence-based protocols for sepsis assessment and management and nurses' compliance with guidelines. Ongoing education training for nurses and providing step-by-step written checklists are a cornerstone to improving nurses' knowledge and the practical skills of early identification and management of sepsis.

The Impact of Nursing Skill-mix on Adverse Events in Intensive Care: A Single Centre Cohort Study

BACKGROUND

The highly complex and technological environment of critical care manages the most critically unwell patients in the hospital system, as such there is a need for a highly trained nursing workforce. Intensive care is considered a high-risk area for errors and adverse events (AE) due to the severity of illness and number of procedures performed.

OBJECTIVE

To investigate if the percentage of Critical Care Registered Nurses (CCRN) within an Intensive Care Unit (ICU) is associated with an increased risk of patients experiencing an AE.

DESIGN & SETTING

We conducted a retrospective cohort study of patients admitted between January 2016 and December 2020 to a tertiary ICU in Australia. Descriptive statistics and multivariable logistic regression were used to investigate the relationship between the proportion of CCRNs each month and the occurrence of an AE defined as any one of a medication error, fall, pressure injury or unplanned removal of a central venous catheter or endotracheal tube per patient.

RESULTS

A total of 13,560 patients were included in the study, with 854 (6.3%) experiencing one AE. Patients with an AE were associated with higher illness severity and frailty scores. They were more commonly admitted after medical emergency team response calls and were less commonly elective ICU admissions. Those with an AE had longer ICU and in-hospital length of stay, and higher ICU and in-hospital mortality, on average. After adjusting for ICU LOS and acute severity of illness, being admitted during a month of higher critical care nursing skill-mix was associated with a statistically significant lower odds of having a subsequent AE (OR 0.966 [95% CI: 0.944-0.988], p 0.003).

CONCLUSION

An increasing percentage of CCRNs is independently associated with a lower risk-adjusted likelihood of an AE. Increasing the skill-mix of the ICU nursing staff may reduce the occurrence of AEs and lead to improved patient outcomes.

Impact of secondary sepsis on mortality in adult intensive care unit patients

RATIONALE

Septic patients admitted to the intensive care unit (ICU) suffer from immune dysregulation, potentially leading to a secondary sepsis episode. This study aims to (i) assess the secondary sepsis rate, (ii) compare the second with the first episodes in terms of demographics, clinical and laboratory characteristics, and outcomes, and iii) evaluate the outcome of secondary sepsis.

METHODS

A single-center, retrospective study (2014-2017) was conducted in a Greek ICU, including consecutive cases of adult patients admitted to the ICU for at least 48 h with a principal admission diagnosis of sepsis and stayed for at least 48 h. We searched for a secondary episode of sepsis following the primary-one. We performed survival analyses with Cox proportional hazard, Fine-Gray, and multistate models.

RESULTS

In this study, 121 patients that fulfilled the eligibility criteria were included. The secondary sepsis group included 28 (23.1 %) patients, with episode onset, median (interquartile range), 9.5 (7.7-16.2) days after ICU admission, who had less frequently had a medical admission diagnosis, a microbiologically confirmed first episode, and the C-reactive protein was lower. The overall ICU mortality of the cohort was 44.6 %. The group that developed secondary sepsis had higher mortality, but significance was lost in Cox regression [Hazard ratio (95 % CI) 0.59(0.31-1.16)]. However, after multistate modeling adjustment, the attributable mortality was estimated at 43.9 % (95 %CI ± 14.8 %).

CONCLUSION

Secondary sepsis was evident in a quarter of the study participants and may be associated with an increased risk of death.

Epidemiology and Age-Related Mortality in Critically Ill Patients With Intra-Abdominal Infection or Sepsis: An International Cohort Study

BACKGROUND

The objective of this study is to describe the epidemiology and age-related mortality in older critically ill adults with intra-abdominal infections.

METHODS

This is a secondary analysis of a prospective, multinational, observational study (AbSeS, ClinicalTrials.gov #NCT03270345) including patients with intra-abdominal infection from 309 ICUs in 42 countries (January-December, 2016). Mortality was considered as ICU mortality with a minimum of 28 days of observation when patients were discharged earlier. Relationships with mortality were assessed by logistic regression analysis.

RESULTS

The cohort included 2337 patients. Four age groups were defined: middle-aged patients as reference category (40-59 years; n=659 [28.2%]), young-old (60-69 years; n=622 [26.6%]), middle-old (70-79 years; n=667 [28.5%]) and very-old patients (≥80 years; n=389 [16.6%]). Secondary peritonitis was the predominant infection (68.7%) and equally prevalent across age groups. Mortality increased with age: 20.9% in middle-aged patients, 30.5% in young-old, 31.2% in middle-old, and 44.7% in very-old patients (p<0.001). Compared to middle-aged patients, young-old age (OR 1.62, 95% CI 1.21-2.17), middle-old age (OR 1.80, 95% CI 1.35-2.41), and very-old age (OR 3.69, 95% CI 2.66-5.12) were independently associated with mortality. Other independent risk factors for mortality included late-onset hospital-acquired intra-abdominal infection, diffuse peritonitis, sepsis/septic shock, source control failure, liver disease, congestive heart failure, diabetes, and malnutrition.

CONCLUSIONS

For ICU patients with intra-abdominal infections, age above 60 years was associated with mortality while patients above 80 years had the worst prognosis. Comorbidities and overall disease severity further compromised survival. As all these factors are non-modifiable it remains unclear how to improve outcomes.

Retrospective Analysis of the Clinical Efficacy of Early Goal-Directed Therapy Combined with Meticulous Nursing Intervention in Patients with Posttraumatic Sepsis

Objective

To explore the intervention effect of early goal-directed therapy (EGDT) combined with meticulous nursing on patients with posttraumatic sepsis.

Methods

The data of 50 patients with posttraumatic sepsis undergoing EGDT in the emergency department of our hospital from January 2020 to December 2020 were retrospectively analyzed. According to different nursing methods, they were divided into control group (n = 25) with routine nursing measures and observation group (n = 25) with meticulous nursing measures. The application effect of the two nursing modes was scientifically evaluated.

Results

No statistical differences in general data were found between the two groups (P > 0.05). After 6 h of intervention, the circulatory function, oxygenation function, and renal function of both groups were better than those before intervention, and central venous pressure (CVP), mean arterial pressure (MAP), blood oxygen (PaO₂), oxygenation index (PaO₂/FiO₂), central venous oxygen saturation (ScvO₂), and urine volume in the observation group were notably higher than those in the control group (P < 0.05). The heart rate (HR), serum creatinine (SCr), and blood lactic acid in the observation group were notably lower than those in the control group (P < 0.05). The 28-day survival rate and quality of life after intervention in the observation group were notably higher than those in the control group, with obvious differences between the two groups (P < 0.05).

Conclusion

Meticulous nursing intervention for patients with posttraumatic sepsis undergoing EGDT can effectively improve the body's functional indexes, which is superior to the routine nursing in controlling the patients' condition, improving the survival rate and quality of life after intervention, and ensuring the clinical treatment effect. Therefore, it is worthy of promotion.

Outcomes of daytime nurse practitioner-staffed versus resident-staffed nonsurgical intensive care units: A retrospective observational study

BACKGROUND

Rapid developments in medical care-such as monitoring devices, medications, and working hours restrictions for intensive care personnel-have dramatically increased the demand for intensive care physicians. Therefore, nurse practitioner (NP)-staffed care is becoming increasingly important. This study was aimed to compare the outcomes of daytime NP-staffed and daytime resident-staffed nonsurgical intensive care units (ICU).

METHODS

We retrospectively assessed patients admitted to a nonsurgical ICU from March 2017 to December 2017. We collected basic patient data, including age, sex, admission diagnosis, transferring unit, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Primary endpoints were ICU mortality, hospital mortality, and 30-day mortality. Secondary endpoints were 48-h readmission, discharge to nonhome locations, and lengths of ICU and hospital stay.

RESULTS

A total of 838 subjects were analysed: 334 subjects in the NP-staffed group and 504 in the resident-staffed group. The NP-staffed group was more likely to come from inpatient units (38.3% vs 16.5% for resident-staffed group; p < 0.001) and had lower disease severity (APACHE II score, 13.9 ± 8.4 vs 15.1 ± 8.2 for resident-staffed group; p = 0.047). After adjusting for age, sex, location before ICU admission, APACHE II score, and significantly different basic characteristics, there were no differences in ICU mortality, hospital mortality, or 30-day mortality between the two groups. Secondary analysis showed the NP-staffed group had a lower discharge rate to nonhome locations (2.1% vs 6.3%; p = 0.023) and shorter hospital stay (12.1 ± 14.1 vs 14.2 ± 14.3 days; p = 0.015).

CONCLUSIONS

We observed no difference in mortality between daytime NP-staffed and resident-staffed nonsurgical ICUs. Daytime NP-staffed care is an effective, safe, feasible method for staffing nonsurgical ICUs.

Knowledge translation following the implementation of a state-wide Paediatric Sepsis Pathway in the emergency department- a multi-centre survey study

Background

Several health care systems internationally have implemented protocolised sepsis recognition and treatment bundles for children to improve outcomes, as recommended by the Surviving Sepsis Campaign. Successful implementation of clinical pathways is challenging and dependent on nurse engagement. There is limited data on knowledge translation during implementation of sepsis quality improvement programs.

Methods

This cross-sectional, multicentre observational survey study evaluated knowledge and perceptions of Emergency Department nurses in relation to the recognition, escalation and management of paediatric sepsis following implementation of a sepsis pathway. The study was conducted between September 2019 and March 2020 across 14 Emergency Departments in Queensland, Australia. The primary outcome was a sepsis knowledge score. An exploratory factor analysis was conducted to identify factors impacting nurses’ perceptions of recognition, escalation and management of paediatric sepsis and their association with knowledge. Using a logistic mixed effects model we explored associations between knowledge, identified factors and other clinical, demographic and hospital site variables.

Results

In total, 676 nurses responded to the survey and 534 were included in the analysis. The median knowledge score was 57.1% (IQR = 46.7–66.7), with considerable variation observed between sites. The exploratory factor analysis identified five factors contributing to paediatric sepsis recognition, escalation and management, categorised as 1) knowledge and beliefs, 2) social influences, 3) beliefs about capability and skills delivering treatment, 4) beliefs about capability and behaviour and 5) environmental context. Nurses reported strong agreement with statements measuring four of the five factors, responding lowest to the factor pertaining to capability and skills delivering treatment for paediatric sepsis. The factors knowledge and beliefs, capability and skills, and environmental context were positively associated with a higher knowledge score. Years of paediatric experience and dedicated nurse funding for the sepsis quality improvement initiative were also associated with a higher knowledge score.

Conclusion

Translation of evidence to practice such as successful implementation of a sepsis care bundle, relies on effective education of staff and sustained uptake of protocols in daily practice. Our survey findings identify key elements associated with enhanced knowledge including dedicated funding for hospitals to target paediatric sepsis quality improvement projects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07128-2.

Challenges in the recognition and management of paediatric sepsis - The journey

Paediatric sepsis remains a leading cause of childhood death. Morbidity is high, with up to one third of children affected developing ongoing, sometimes lifelong sequelae. To address the major burden of sepsis on child health, there is need for a unified approach to care, as outlined in the Australian National Action Plan for sepsis. While the Surviving Sepsis Campaign 2020 guidelines provided evidence-based recommendations for sepsis management in hospital, additional emphasis on families, pre-hospital recognition and post-sepsis care incorporating the multidisciplinary team is paramount to achieve quality patient outcomes. The role of families, paramedics and nurses in recognising and managing paediatric sepsis remains an under-represented area in current literature. The aim of this paper is to critically discuss key challenges surrounding the journey of paediatric sepsis, drawing on contemporary literature to highlight key areas pertinent to recognition and management of sepsis in children. Application of a holistic, patient-centred focus will provide an overview of paediatric sepsis, aiming to inform future development for enhanced healthcare delivery and identify critical areas for further research.

Current Key Challenges in Managing Maternal Sepsis

Sepsis resulting from maternal infection is the second leading cause of pregnancy-related death. Although screening and initial care of a septic nonpregnant patient is standardized in nonpregnant adults, many challenges exist for early recognition and management of sepsis and septic shock in the obstetric population. Because most sepsis research excludes pregnant patients, there are many challenges that contribute to a lack of standardized approach to maternal sepsis. These challenges include inconsistent early warning sign criteria, lack of validated screening tools, adaptation of bundle components for maternal physiology, delivery considerations, and knowing when to transfer the patient to a higher level of care. To overcome these challenges, reduce variation in care, and improve patient outcomes, it is important for clinicians to plan, practice, and implement a maternal sepsis bundle.

Intensive Care Unit Nursing Priorities in the United States

This integrative review presents the most recent and relevant critical care nursing research publications in the United States. A comprehensive search identified publications on the topics of delirium; early mobility; communication; palliative care; tele-intensive care unit; care bundle implementation; and prevention, detection, and early management of infection. The evidence is summarized for each of these topics, as well as other research, with suggestions and guidance for end users.