Critical care nurses' role in implementing the "ABCDE bundle" into practice

Nurses' care coordination competence in mechanically ventilated patients in intensive care units: a cross-sectional study

BACKGROUND

The intensive care unit (ICU) is crucial in treating severely ill patients, particularly those requiring mechanical ventilation. Nurses are essential for coordinating care and addressing any gaps within the ICU team. This study aimed to evaluate the care coordination competency of nurses in Iranian ICUs, specifically about mechanically ventilated patients.

METHODS

A descriptive cross-sectional study was conducted at Guilan University of Medical Science from September to December 2022, involving 211 ICU nurses selected through convenience sampling. The Nurses' Coordination Competency Scale (NCCCS) and a demographic information form were used. Statistical analyses were conducted using SPSS version 16, including Pearson correlation, independent t-tests, one-way ANOVA, and multiple linear regression analysis, with a significance level set at 0.05.

RESULTS

The mean score on the NCCCS for nurses was 3.41 out of 5. The multivariable analysis identified key factors influencing coordination competency, including a Master of Science in Nursing (MSN) degree (b = 0.891, P < 0.001), prior ICU experience (b = 0.080, P < 0.001), and fixed shift employment (b = 0.500, P = 0.011) scored higher on the NCCCS. Conversely, those in commitment-type positions had lower scores than those in standard roles (b=-0.690, P < 0.001).

CONCLUSION

The study found that Iranian ICU nurses demonstrated high competency in coordinating care for mechanically ventilated patients. However, they must improve teamwork, align their understanding of patient care needs, and enhance team cohesion through training and advanced technologies.

Nurse-involved early mobilization in the intensive care unit: A systematic review and meta-analysis

BACKGROUND

Early mobilization is one proposed strategy for reducing complications and optimizing patient outcomes. Nurses play an essential role in patient monitoring and co-ordination.

AIMS

To assess the effects of a nurse-involved early mobilization programme on muscle strength and intensive care unit (ICU) length of stay and identify the components of an early mobilization programme.

STUDY DESIGN

A systematic review and meta-analysis were conducted. MEDLINE (PubMed), Embase, Cochrane and CINAHL databases were searched. Eligible studies included randomized controlled trials (RCTs) and non-randomized studies of adult ICU patients undergoing early mobilization. The studies were appraised using RoB 2.0 and ROBINS-I tools, and a meta-analysis was performed using Rstudio 2023.06.2.

RESULTS

Nine studies were selected from 943 studies. Four studies involved only ICU nurses, while five involved multidisciplinary teams. Concerns about bias were raised in four RCTs, and two non-randomized studies had moderate bias risk. Interventions involved progressive exercise steps, but none detailed the specific role of nurses. Early mobilization significantly decreased ICU length of stay (95% CI: -3.22, -0.11; p = .04), although it did not improve muscle strength (95% CI: -0.86, 0.99; p = .80).

CONCLUSIONS

Nurse-involved early mobilization was associated with a reduction in ICU stay, although it did not impact muscle strength. The nurses' roles were not specifically defined.

RELEVANCE TO CLINICAL PRACTICE

An analysis of relevant tasks is necessary to clarify the role of nurses in early mobilization and to provide optimal care. Including these roles is crucial in the development of standardized early mobilization.

Effect of educational program on nurses' performance regarding application of liberation bundle in pediatric intensive care unit

BACKGROUND

Recent guidelines in paediatric critical care emphasize the implementation of the evidence-based liberation bundle to improve patient outcomes in paediatric intensive care units (PICUs). However, there is limited information on the application of this bundle in Egyptian hospitals, and the effectiveness of educational programs on nurse performance in this context remains unclear.

AIM

This study aimed to evaluate the effect of an educational program on nurses' performance regarding the application of the liberation bundle in paediatric intensive care unit.

METHODS

A one-group pre/post quasi-experimental design was employed. The study was conducted in the PICUs of Al-Azhar University Hospital and Menoufia University Hospital, involving a convenient sample of 52 paediatric nurses. Data were collected using two tools: a predesigned questionnaire to assess knowledge about the liberation bundle and an observational checklist to evaluate nurse practices before and after the educational program.

RESULTS

The results demonstrated significant improvements in nurses' knowledge and practices post-intervention. The studied nurses' total level of knowledge regarding the liberation bundle increased from 13.7 to 92.3% post-educational program X2 (P. value) = 89.143(0.000). The studied nurses' total level of practices regarding the liberation bundle increased from 9.6 to 80.8% post-educational program X2 (P. value) = 89.143(0.000).

CONCLUSION

The educational program significantly enhanced the nurses' knowledge and practices in applying the liberation bundle in PICUs. This improvement in knowledge and practices is expected to lead to better outcomes for paediatric patients, including reduced mortality, shorter PICU stays, and fewer post-intensive care complications. By equipping nurses with the skills to implement the bundle, the program can improve recovery and long-term health outcomes in critically ill children.

Status quo and influencing factors of multiprofessional and multidisciplinary teamwork for early mobilization in mechanically ventilated patients in ICUs: A multi-centre survey study

AIM

To understand the status quo of multiprofessional and multidisciplinary collaboration for early mobilization of mechanically ventilated patients in Chinese ICUs and identify any factors that may influence this practice.

DESIGN

A multi-centre cross-sectional survey.

METHODS

From October to November 2022, the convenience sampling method was used to select ICU multiprofessional and multidisciplinary early mobility members (including physicians, nurses and physiotherapists) from 27 tertiary general hospitals in 14 provinces, cities and autonomous regions of China. They were asked to complete an author-developed questionnaire on the status of collaboration and the Assessment of Inter-professional Team Collaboration Scale. A multiple linear regression model was used to analyse the factors associated with the level of collaboration.

RESULTS

Physicians, nurses and physiotherapists mostly suffered from the lack of normative protocols, unclear division of responsibilities and unclear multiprofessional and multidisciplinary teams when using a collaborative approach to early activities. Multiple linear regression analysis showed that the number of ICU patients managed, the existence of norms and processes, the attitude of colleagues around them, the establishment of a team, communication methods and activity leaders were significant influences on the level of collaboration among members of the multiprofessional and multidisciplinary early activities.

CONCLUSION

The collaboration of multiprofessional and multidisciplinary early activity members for mechanically ventilated patients in the ICU remains unclear, and the collaboration strategy needs to be constructed and improved, taking into account China's human resources and each region's economic development level.

IMPACT

This study investigates the collaboration status of multiprofessional and multidisciplinary activity members from the perspective of teamwork, analyses the reasons affecting the level of collaboration and helps to develop better teamwork strategies to facilitate the implementation of early activities.

PATIENT OR PUBLIC CONTRIBUTION

The participants in this study were multiprofessional and multidisciplinary medical staff who performed early activities for ICU patients.

Practices of the ABCDEF care bundle in intensive care units as reported by nurses: A cross-sectional study from Turkey

BACKGROUND

Recent critical care guidelines recommended the evidence-based ABCDEF care bundle for intensive care unit (ICU) patients. However, limited information is available on the implementation of the bundle in Turkish ICUs.

AIM

To assess the current practices of the ABCDEF care bundle as reported by ICU nurses.

STUDY DESIGN

A cross-sectional study using a web-based survey was conducted. Researchers invited nurses with at least 1 year of ICU experience to participate by sending the link to the research questionnaires they created in Google Forms to the one ICU nurse association and one communication group of which they are members.

RESULTS

A total of 342 ICU nurses completed the survey. Although 92% of the participants performed pain assessments in their ICUs, 52.7% reported not using protocols. Based on the responses of the nurses, spontaneous awakening and breathing trials are performed in 88.8% and 92.4%, respectively, of ICUs. Fewer than half of the participants reported following a sedation protocol in their ICUs. Only 54.7% of ICU nurses surveyed reported routinely monitoring patients for delirium. It was reported that early mobilization was practised in 68.7% of ICUs, but non-ventilated patients were mobilized more frequently (70.2%), and 9.7% of ICUs had mobilization teams. Family members were actively involved in 95% of ICUs; however, 9.7% used dedicated staff to support families and 3.5% reported that their unit was open 24 h/day for visits.

CONCLUSIONS

While the implementation of most pain and sedation evaluations in ICUs were reported by nurses, many of them did not use structured delirium assessments. There is a need to encourage early mobilization programs and family participation.

RELEVANCE TO CLINICAL PRACTICE

Health institutions can improve patient care and outcomes by establishing and standardizing a protocol for each component of the ABCDEF care bundle in ICUs.

Knowing your team in the intensive care unit: an ethnographic study on familiarity

Effective interprofessional team function is integral to high-quality care in the intensive care unit (ICU). However, little is known about how familiarity develops among teams, which may be an important antecedent to effective team function and quality care. To examine team familiarity and how it impacts ICU team function and care, we conducted an ethnographic study in four ICUs (two medical ICUs, one mixed medical-surgical ICU, and one surgical ICU) in two community hospitals and one academic medical center. We conducted 57.5 h of observation, 26 shadowing experiences, and 26 interviews across the four ICUs sequentially. We used thematic analysis to examine familiarity among the team. We found that ICU team members become familiar with their team through interpersonal, relational interactions, which involved communication, time working together, social interactions, trust, and respect. Our findings underscore the relational aspect of effective teams and demonstrate that time working together, social interactions, communication, developing trust, and respect are pathways to familiarity and optimal team function. Leveraging unique and creative ways to enhance the relational aspects of ICU teams could be an area for future research and lead to improved ICU outcomes.

Pain management interventions of the non-communicating patient in intensive care: What works for whom and why? A rapid realist review

AIM

The utility and uptake of pain management interventions across intensive care settings is inconsistent. A rapid realist review was conducted to synthesise the evidence for the purpose of theory building and refinement.

DESIGN

A five-step iterative process was employed to develop project scope/ research questions, collate evidence, appraise literature, synthesise evidence and interpret information from data sources.

METHODS

Realist synthesis method was employed to systematically review literature for developing a programme theory.

DATA SOURCES

Initial searches were undertaken in three electronic databases: MEDLINE, CINHAL and OVID. The review was supplemented with key articles from bibliographic search of identified articles. The first 200 hits from Google Scholar were screened.

RESULTS

Three action-oriented themes emerged as integral to successful implementation of pain management interventions. These included health facility actions, unit/team leader actions and individual nurses' actions.

CONCLUSION

Pain assessment interventions are influenced by a constellation of factors which trigger mechanisms yielding effective implementation outcomes.

IMPLICATIONS

The results have implications on policy makers, health organisations, nursing teams and nurses concerned with optimising the successful implementation of pain management interventions.

IMPACT

The review enabled formation of a programme theory concerned with explaining how to effectively implement pain management interventions in intensive care.

REPORTING METHOD

This review was informed by RAMESES publication standards for realist synthesis.

PUBLIC CONTRIBUTION

No patient or public contribution. The study protocol was registered in Open Science Framework. 10.17605/OSF.IO/J7AEZ.

Longitudinal study on the trajectory and influencing factors of cognitive dysfunction in lung transplantation patients

INTRODUCTION

Lung transplantation is an effective method for treating end-stage lung disease. It prolongs the survival time of patients, improves the quality of life, and prevents the degree of mental disability. In particular, postoperative cognitive dysfunction (POCD) is one of the complications after lung transplantation. Despite this, longitudinal studies on the identification and heterogeneity of cognitive dysfunction subgroup trajectories in transplant patients are lacking. Therefore, our study aimed to evaluate the factors that influence POCD in lung transplant patients.

METHODS

This prospective longitudinal study included patients who underwent lung transplantation at the transplant center of Wuxi People's Hospital from September 2022 to September 2023. Patients with lung transplants were evaluated at 8 days (T1), 1 month (T2), 3 months (T3), and 6 months (T4) after the operation. The general information questionnaire evaluated cognitive functions using the Montreal Cognitive Assessment (MoCA) numerical rating scale (NRS) and the digital pain assessment to obtain the POCD values. Latent category growth model (LCGM) analysis was used to identify heterogeneous POCD subgroups in the four observation periods. Univariate and logistic regression analyses were used to identify factors affecting POCD classification and independent risk factors.

RESULTS

Based on clinical outcomes, 79 patients completed all four surveys, of whom 16 were lost during the follow-up period (loss rate, 16.8%). The cognitive function by MoCA NRS score was 14.18 ± 5.32 points on day 8 (T1), 22.51 ± 5.13 points at 1 month (T2), 25.44 ± 3.61 at 3 months (T3), and 27.04 ± 3.03 points at 6 months (T4) after lung transplantation, showing an increasing trend. The LCGM, used to fit the trajectory of MoCA scores, observed a heterogeneous trajectory of changes in lung transplant patients. Based on this analysis, patients could be divided into two categories: those with high risk (25,32%) and those with low risk (54,68%). The single-factor analysis identified that POCD values were affected by early postoperative rehabilitation exercise, degree of pain, intensive care unit (ICU) stay time, and donor lung cold ischemia time (all P < 0.05). Using the low-risk group as the reference class, logistic regression analysis showed that the model could correctly classify the subjects.

CONCLUSION

Our 6-month observation of lung transplant patients showed that the degree of cognitive dysfunction had an overall downward trend and that patients could be divided into two trajectories of high and low risk for POCD. Early postoperative rehabilitation exercise, degree of pain, ICU stay time, and donor lung cold ischemia time were all influencing factors for POCD in lung transplant patients.

Incidence, outcome, and prognostic factors of prolonged mechanical ventilation among children in Chinese mainland: a multi-center survey

Objective

To evaluate the incidence, outcome, and prognostic factors of prolonged mechanical ventilation (PMV) in children in Mainland China.

Methods

A prospective study was conducted in 11 pediatric intensive care units (PICUs) from May 1, 2021, to April 30, 2022. All pediatric patients on mechanical ventilation meeting the criteria for PMV were included in the study.

Results

Out of 5,292 patients receiving mechanical ventilation, 278 children met the criteria for PMV (5.3%). After excluding case with incomplete data or lost to follow-up, the study included 250 patients. Among them, 115 were successfully weaned from mechanical ventilation, 90 died, and 45 were still on mechanical ventilation. The 6-month survival rate was 64%. The primary associated conditions of PMV were lower airway diseases (36%), central nervous system diseases (32%), and neuromuscular diseases (14%). The stepwise multiple logistic regression analysis indicated that the utilization of vasoactive agents and an elevated pediatric logistic organ dysfunction-2 (PELOD-2) score on the day of PMV diagnosis were significantly associated with an increased of PMV death. Specifically, the odds ratio (OR) for vasoactive agent use was 2.86; (95% CI: 0.15-0.84; P = 0.018), and for the PELOD-2 score, it was 1.37; 95% CI: 1.17-1.61; P < .001). Conversely, early rehabilitation intervention was negatively associated with the risk of PMV death (OR = 0.45; 95% CI: 0.22-0.93; P = .032). Furthermore, the tracheotomy timing emerged as an independent predictor of failure to wean from PMV, with an OR of 1.08, (95% CI: 1.01-1.16; P = .030).

Conclusions

The study revealed a 5.3% incidence of PMV in children requiring mechanical ventilation in China. The use of vasoactive agents and a higher PELOD-2 score at PMV diagnosis were significantly associated with an increased risk of PMV death, whereas early rehabilitation intervention was identified as crucial for improving patient outcomes. The timing of tracheostomy was identified as a high-risk factor for failure to wean from mechanical ventilation.

Patterns of interactions among ICU interprofessional teams: A prospective patient-shift-level survey approach

BACKGROUND

The Awakening, Breathing Coordination, Delirium monitoring and Early mobility bundle (ABCDE) is associated with lower mortality for intensive care unit (ICU) patients. However, efforts to improve ABCDE are variably successful, possibly due to lack of clarity about who are the team members interacting when caring for each patient, each shift. Lack of patient shift-level information regarding who is interacting with whom limits the ability to tailor interventions to the specific ICU team to improve ABCDE.

OBJECTIVE

Determine the number and types of individuals (i.e., clinicians and family members) interacting in the care of mechanically ventilated (MV) patients, as reported by the patients' assigned physician, nurse, and respiratory therapist (RT) each shift, using a network science lens.

METHODS

We conducted a prospective, patient-shift-level survey in 2 medical ICUs. For each patient, we surveyed the assigned physician, nurse, and RT each day and night shift about who they interacted with when providing ABCDE for each patient-shift. We determined the number and types of interactions, reported by physicians, nurses, and RTs and day versus night shift.

RESULTS

From 1558 surveys from 404 clinicians who cared for 169 patients over 166 shifts (65% response rate), clinicians reported interacting with 2.6 individuals each shift (physicians: 2.65, nurses: 3.33, RTs: 1.86); this was fewer on night shift compared to day shift (1.99 versus 3.02). Most frequent interactions were with the bedside nurse, attending, resident, intern, and RT; family member interactions were reported in less than 1 in 5 surveys (12.2% of physician surveys, 19.7% of nurse surveys, 4.9% of RT surveys).

INTERPRETATION

Clinicians reported interacting with 3-4 clinicians each shift, and fewer on nights. Nurses interacted with the most clincians and family members. Interventions targeting shift-level teams, focusing on nurses and family members, may be a way to improve ABCDE delivery and ICU teamwork.

Effectiveness of a self-assessment application in evaluating the care coordination competency of intensive care unit nurses in managing patients on life support: An intervention study

AIM

To examine the effectiveness of the feedback from the Nurses' Care Coordination Competency Scale (NCCCS) application (app) used for self-assessing the care coordination competency of intensive care unit (ICU) nurses in managing patients on life support.

METHODS

A non-randomized open-label study was conducted in Japan from November 2021 to March 2022. Participants were 318 ICU nurses from acute hospitals in Japan. They were divided manually into two groups based on their certification status. The intervention was immediate feedback on the results of the care coordination competency self-assessment through the NCCCS app; the control group performed the NCCCS survey with no feedback. The primary outcome was an increase in the NCCCS score 1 month after the intervention. Mann-Whitney U test was used to compare the scores of the intervention and control groups. Wilcoxon's signed rank sum test was used to compare the scores in the first and second NCCCS surveys.

RESULTS

Forty-one participants were lost to follow-up, leaving 277 participants (intervention = 141, control = 136) for analysis. One month later, NCCCS scores similarly increased in both groups. For nurses with at least 5 years of ICU experience (n = 152), the NCCCS score increased in the intervention group (n = 75) (rising point mean: 4.8, standard deviation [SD]: 9.8) compared with that in the control group (n = 77) (rising point mean: 1.3, SD: 8.3) (p = .048).

CONCLUSIONS

Feedback from the NCCCS app can improve care coordination behavior. However, a certain level of ICU experience may be required to translate feedback into improved behavior.

Physicians' Knowledge of the Systematic ABCDE Approach in Riyadh, Saudi Arabia

Purpose

To evaluate physicians' knowledge of the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach components.

Methods

A cross-sectional study was conducted in 2023 using an online questionnaire in order to collect data about the knowledge of the ABCDE approach's components among physicians in different specialties in Riyadh, Saudi Arabia.

Results

The number of participants were 165 in total and the median knowledge score for all participants was 15.0, with an associated interquartile range (IQR) of 10.0 to 20.0. Intensive Care Medicine had the highest median knowledge score of 19.0 (IQR: 12.0-21.0), followed by Internal Medicine at 17.0 (IQR: 13.0-20.0). Conversely, Cardiology and Anesthesiology showed lower scores, with medians of 8.0 (IQR: 4.0-10.0) and 7.5 (IQR: 4.0-13.5), respectively (p = 0.011). Senior Registrars demonstrated the highest median knowledge score of 20.0 (IQR: 14.0-22.0), while Fellows had the lowest at 8.5 (IQR: 7.0-13.0) (p < 0.001). Practicing for 10 to 15 years and more than 15 years having medians of 20.0 (IQR: 16.0-23.0) and 19.0 (IQR: 17.0-22.0), respectively. However, participants with less experience, working for less than 5 years, had a median score of 12.0 (IQR: 8.5-16.5) (p < 0.001).

Conclusion

Knowledge scores of physicians representing various medical specialties found diverse levels regarding the ABCDE approach. Knowledge scores were significantly influenced by the primary area of practice, level of experience, and duration worked in the profession, highlighting the need for tailored training and education across different specialties and career stages. On the other hand, future studies should concentrate on finding new factors that influence practice adherence to the ABCDE approach and tying theoretical knowledge to clinical practice.

Communication with mechanically ventilated patients in intensive care units: A concept analysis

AIMS

The aim of this study was to perform a concept analysis of communication with mechanically ventilated patients in intensive care units and present a preliminary model for communication practice with these patients.

DESIGN

The Im & Meleis approach for concept analysis guided the study.

SEARCH METHODS

A literature search was performed in January 2022 in MEDLINE, Embase, CINAHL, psycINFO and Scopus, limited to 1998-2022. The main medical subject headings search terms used were artificial respiration, communication and critical care. The search resulted in 10,698 unique references.

REVIEW METHODS

After a blinded review by two authors, 108 references were included. Core concepts and terminology related to communication with mechanically ventilated patients were defined by content analytic methods. The concepts were then grouped into main categories after proposing relationships between them. As a final step, a preliminary model for communication with mechanically ventilated patients was developed.

RESULTS

We identified 39 different phrases to describe the mechanically ventilated patient. A total of 60 relevant concepts describing the communication with mechanically ventilated patients in intensive care were identified. The concepts were categorized into five main categories in a conceptual map. The preliminary model encompasses the unique communication practice when interacting with mechanically ventilated patients in intensive care units.

CONCLUSION

Highlighting different perspectives of the communication between mechanically ventilated patients and providers through concept analysis has contributed to a deeper understanding of the phenomena and the complexity of communication when the patients have limited possibilities to express themselves.

IMPACT

A clear definition of concepts is needed in the further development of guidelines and recommendations for patient care in intensive care, as well as in future research. The preliminary model will be tested further.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution, as this is a concept analysis of previous research.

Clinical Practice Guideline: Early Mobilization and Rehabilitation of Critically Ill Burn Patients

This Clinical Practice Guideline addresses early mobilization and rehabilitation (EMR) of critically ill adult burn patients in an intensive care unit (ICU) setting. We defined EMR as any systematic or protocolized intervention that could include muscle activation, active exercises in bed, active resistance exercises, active side-to-side turning, or mobilization to sitting at the bedside, standing, or walking, including mobilization using assistance with hoists or tilt tables, which was initiated within at least 14 days of injury, while the patient was still in an ICU setting. After developing relevant PICO (Population, Intervention, Comparator, Outcomes) questions, a comprehensive literature search was conducted with the help of a professional medical librarian. Available literature was reviewed and systematically evaluated. Recommendations were formulated through the consensus of a multidisciplinary committee, which included burn nurses, physicians, and rehabilitation therapists, based on the available scientific evidence. No recommendation could be formed on the use of EMR to reduce the duration of mechanical ventilation in the burn ICU, but we conditionally recommend the use of EMR to reduce ICU-acquired weakness in critically ill burn patients. No recommendation could be made regarding EMR's effects on the development of hospital-acquired pressure injuries or disruption or damage to the skin grafts and skin substitutes. We conditionally recommend the use of EMR to reduce delirium in critically ill burn patients in the ICU.

Effect of Early Multidisciplinary Collaboration Combined with Cluster Strategy on Acquired Debilitating Syndrome in ICU of Patients with Acute Myocardial Infarction

Background

To investigate the preventive effect of early multidisciplinary collaboration combined with cluster strategy on acquired frailty syndrome in ICU of patients with acute myocardial infarction (AMI).

Methods

A total of 240 patients with myocardial infarction (MI) admitted to ICU in The Third Affiliated Hospital of Qiqihar Medical University, Qiqihar, China from March 2018 to March 2020 were selected. The patients were randomly divided into experiment group and control group equally according to random number method. The experimental group was treated with early multidisciplinary collaboration and cluster strategy, while the control group was treated with routine nursing mode. Duration of ventilation, total length of stay, length of ICU stay, New York College of Cardiology cardiac function classification, MRC-Score, BI and complications during hospitalization were recorded.

Results

After intervention, there were statistically significant differences in ventilation duration, total length of stay, length of stay in ICU, Heart function classification of New York Cardiology Society, MRC-Score, BI index, SF-36 score and complications during hospitalization in 2 groups (P < 0.05), and the above indicators in the experimental group were better than those in the control group.

Conclusion

Early multidisciplinary collaboration combined with cluster strategy can significantly reduce the incidence of AMI in ICU of MI patients.

Evaluation of progressive early rehabilitation training mode in intensive care unit patients with mechanical ventilation

BACKGROUND

Mechanical ventilation is a common resuscitation method in the intensive care unit (ICU). Unfortunately, this treatment process prolongs the ICU stay of patients with an increased incidence of delirium, which ultimately affects the prognosis.

AIM

To evaluate the effect of progressive early rehabilitation training on treatment and prognosis of patients with mechanical ventilation in ICU.

METHODS

The convenience sampling method selected 190 patients with mechanical ventilation admitted to the Fourth Hospital of Hebei Medical University from March 2020 to March 2021. According to the random number table method, they were divided into the control and intervention groups. The control group received routine nursing and rehabilitation measures, whereas the intervention group received progressive early rehabilitation training. In addition, the incidence and duration of delirium were compared for the two groups along with mechanical ventilation time, ICU hospitalization time, functional independence measure (FIM) score, Barthel index, and the incidence of complications (deep venous thrombosis, pressure sores, and acquired muscle weakness).

RESULTS

In the intervention group, the incidence of delirium was significantly lower than in the control group (28% vs 52%, P < 0.001). In the intervention group, the duration of delirium, mechanical ventilation time, and ICU stay were shorter than in the control group (P < 0.001). The FIM and Barthel index scores were significantly higher in the intervention group than the control group (P < 0.001). The total incidence of complications in the intervention group was 3.15%, which was lower than 17.89% in the control group (P < 0.001).

CONCLUSION

Progressive early rehabilitation training reduced the incidence of delirium and complications in ICU patients with mechanical ventilation, which improved prognosis and quality of life.

Prevention and treatment of delirium in intensive care: Hermeneutics of experiences of the nursing team

OBJECTIVE

To understand the experiences in nursing care in the prevention and treatment of delirium in people hospitalized in intensive care units.

METHODOLOGY

Hermeneutic phenomenological qualitative study. The selection of participants was by intentional sampling: seven nursing assistants and eight nurses. Theoretical saturation was achieved. The phenomenological interview was applied to collect data from a central question and the analysis was carried out following the approaches of Heidegger's hermeneutical circle.

RESULTS

Four significant themes emerged from the analysis: (1) delirium prevention, (2) pharmacological treatment, (3) non-pharmacological treatment, and (4) barriers to non-pharmacological treatment. These themes were accompanied by 35 interrelated units of meaning: in the first theme, the most repetitive units were communication, orientation, and family bonding; in the second was the use of pharmacological treatment only in the acute phase; in the third was the modification of the environment according to the patient's preference (where the family is a priority and strategies that provide cognitive and social stimulation can be reinforced), and in the fourth was the work overload for the nursing team.

CONCLUSIONS

The experiences of the nursing team in the prevention and treatment of delirium in critically ill patients highlight that communication allows an approach to the patient as a human being immersed in a reality, with a personal history, needs and preferences. Therefore, family members must be involved in these scenarios, as they can complement and support nursing care.

Machine learning-based suggestion for critical interventions in the management of potentially severe conditioned patients in emergency department triage

Providing timely intervention to critically ill patients is a challenging task in emergency departments (ED). Our study aimed to predict early critical interventions (CrIs), which can be used as clinical recommendations. This retrospective observational study was conducted in the ED of a tertiary hospital located in a Korean metropolitan city. Patient who visited ED from January 1, 2016, to December 31, 2018, were included. Need of six CrIs were selected as prediction outcomes, namely, arterial line (A-line) insertion, oxygen therapy, high-flow nasal cannula (HFNC), intubation, Massive Transfusion Protocol (MTP), and inotropes and vasopressor. Extreme gradient boosting (XGBoost) prediction model was built by using only data available at the initial stage of ED. Overall, 137,883 patients were included in the study. The areas under the receiver operating characteristic curve for the prediction of A-line insertion was 0·913, oxygen therapy was 0.909, HFNC was 0.962, intubation was 0.945, MTP was 0.920, and inotropes or vasopressor administration was 0.899 in the XGBoost method. In addition, an increase in the need for CrIs was associated with worse ED outcomes. The CrIs model was integrated into the study site's electronic medical record and could be used to suggest early interventions for emergency physicians.

Caught between ideals and reality: Phenomenological-hermeneutic study of healthcare providers' experiences while interacting with mechanically ventilated patients

This study aimed to explore healthcare providers' experiences of their communication and interaction with conscious patients on mechanical ventilation in intensive care. Nurses, physicians, and physiotherapists were interviewed after they had been video recorded in naturally occurring interactions with patients. The interviews were analyzed using a phenomenological-hermeneutical approach. Three themes were identified: The willingness to engage and understand the mechanically ventilated patient, the potential risk of neglecting the patient in the encounters, and provider interdependence as the core of intensive care. The themes elicited how providers handled the dissonance between their own personal ideals of care and their real-world encounters with patients and other professionals. The healthcare providers were aware of how easily patients could be neglected while being non-vocal, and therefore invested time and effort communicating with the patients. Based on their personal ideals of patient participation and autonomy, it was difficult to perform procedures, such as weaning off the ventilator or mobilization, to which the patient was opposed. Interprofessional collaboration was valued by the providers in such situations. The study revealed that providers need to consider the communication barriers that exist on the individual and team levels when interacting with patients on mechanical ventilation.

Sustaining a Multidisciplinary, Single-Institution, Postoperative Mobilization Clinical Practice Improvement Program Following Hepatopancreatobiliary Surgery During the COVID-19 Pandemic: Prospective Cohort Study

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) protocol has been recently extended to hepatopancreatobiliary (HPB) surgery, with excellent outcomes reported. Early mobilization is an essential facet of the ERAS protocol, but compliance has been reported to be poor. We recently reported our success in a 6-month clinical practice improvement program (CPIP) for early postoperative mobilization. During the COVID-19 pandemic, we experienced reduced staffing and resource availability, which can make CPIP sustainability difficult.

OBJECTIVE

We report outcomes at 1 year following the implementation of our CPIP to improve postoperative mobilization in patients undergoing major HPB surgery during the COVID-19 pandemic.

METHODS

We divided our study into 4 phases-phase 1: before CPIP implementation (January to April 2019); phase 2: CPIP implementation (May to September 2019); phase 3: post-CPIP implementation but prior to the COVID-19 pandemic (October 2019 to March 2020); and phase 4: post-CPIP implementation and during the pandemic (April 2020 to September 2020). Major HPB surgery was defined as any surgery on the liver, pancreas, and biliary system with a duration of >2 hours and with an anticipated blood loss of ≥500 ml. Study variables included length of hospital stay, distance ambulated on postoperative day (POD) 2, morbidity, balance measures (incidence of fall and accidental dislodgement of drains), and reasons for failure to achieve targets. Successful mobilization was defined as the ability to sit out of bed for >6 hours on POD 1 and ambulate ≥30 m on POD 2. The target mobilization rate was ≥75%.

RESULTS

A total of 114 patients underwent major HPB surgery from phases 2 to 4 of our study, with 33 (29.0%), 45 (39.5%), and 36 (31.6%) patients in phases 2, 3, and 4, respectively. No baseline patient demographic data were collected for phase 1 (pre-CPIP implementation). The majority of the patients were male (n=79, 69.3%) and underwent hepatic surgery (n=92, 80.7%). A total of 76 (66.7%) patients underwent ON-Q PainBuster insertion intraoperatively. The median mobilization rate was 22% for phase 1, 78% for phases 2 and 3 combined, and 79% for phase 4. The mean pain score was 2.7 (SD 1.0) on POD 1 and 1.8 (SD 1.5) on POD 2. The median length of hospitalization was 6 days (IQR 5-11.8). There were no falls or accidental dislodgement of drains. Six patients (5.3%) had pneumonia, and 21 (18.4%) patients failed to ambulate ≥30 m on POD 2 from phases 2 to 4. The most common reason for failure to achieve the ambulation target was pain (6/21, 28.6%) and lethargy or giddiness (5/21, 23.8%).

CONCLUSIONS

This follow-up study demonstrates the sustainability of our CPIP in improving early postoperative mobilization rates following major HPB surgery 1 year after implementation, even during the COVID-19 pandemic. Further large-scale, multi-institutional prospective studies should be conducted to assess compliance and determine its sustainability.

How We Prevent and Treat Delirium in the ICU

Delirium is a serious and complex problem facing critically ill patients, their families, and the health care system. When delirium develops, it is associated with prolonged hospital stays, increased costs, and long-term cognitive impairment in many patients. This article uses a clinical case to discuss our approach to delirium prevention and treatment in the ICU. We believe that an effective strategy to combat delirium requires implementation and adherence to a pain and sedation protocol as part of bundled care, use of a validated tool to detect delirium when present, and a focus on nonpharmacologic care strategies, including reorientation, early mobility, and incorporating family into care when possible. At present, the evidence does not support the routine administration of medications to prevent or treat delirium. A pharmacologic approach may be needed for agitated delirium, and we discuss our evaluation of the evidence for and against particular medications. Although delirium can be a distressing problem, there is evidence that it can be addressed through careful attention to prevention, detection, and minimizing the long-term impact on patients and their families.

Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia/Sedation; Delirium: Assess, Prevent, and Manage; Early Mobility; Family Engagement and Empowerment Bundle Implementation: Quantifying the Association of Access to Bundle-Enhancing Supplies and Equipment

Describe the physical environment factors (i.e., availability, accessibility) of bundle-enhancing items and the association of physical environment with bundle adherence.

DESIGN

This multicenter, exploratory, cross-sectional study used data from two ICU-based randomized controlled trials that measured daily bundle adherence. Unit- and patient-level data collection occurred between 2011 and 2016. We developed hierarchical logistic regression models using Frequentist and Bayesian frameworks.

SETTING

The study included 10 medical and surgical ICUs in six academic medical centers in the United States.

PATIENTS

Adults with qualifying respiratory failure and/or septic shock (e.g., mechanical ventilation, vasopressor use) were included in the randomized controlled trials.

INTERVENTIONS

The Awakening and Breathing trial Coordination, Delirium assessment/management, Early mobility bundle was recommended standard of care for randomized controlled trial patients and adherence tracked daily.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was adherence to the full bundle and the early mobility bundle component as identified from daily adherence documentation (n = 751 patient observations). Models included unit-level measures such as minimum and maximum distances to bundle-enhancing items and patient-level age, body mass index, and daily mechanical ventilation status. Some models suggested the following variables were influential: unit size (larger associated with decreased adherence), a standard walker (presence associated with increased adherence), and age (older associated with decreased adherence). In all cases, mechanical ventilation was associated with decreased bundle adherence.

CONCLUSIONS

Both unit- and patient-level factors were associated with full bundle and early mobility adherence. There is potential benefit of physical proximity to essential items for Awakening and Breathing trial Coordination, Delirium assessment/management, Early mobility bundle and early mobility adherence. Future studies with larger sample sizes should explore how equipment location and availability influence practice.

Prevention and treatment of delirium in intensive care: Hermeneutics of experiences of the nursing team

OBJECTIVE

To understand the experiences in nursing care in the prevention and treatment of delirium in people hospitalized in intensive care units.

METHODOLOGY

Hermeneutic phenomenological qualitative study. The selection of participants was by intentional sampling: seven nursing assistants and eight nurses. Theoretical saturation was achieved. The phenomenological interview was applied to collect data from a central question and the analysis was carried out following the approaches of Heidegger's hermeneutical circle.

RESULTS

Four significant themes emerged from the analysis: 1) Delirium prevention, 2) Pharmacological treatment, 3) Non-pharmacological treatment, and 4) Barriers to non-pharmacological treatment. These themes were accompanied by 35 interrelated units of meaning: in the first theme, the most repetitive units were communication, orientation, and family bonding; in the second was the use of pharmacological treatment only in the acute phase; in the third was the modification of the environment according to the patient's preference (where the family is a priority and strategies that provide cognitive and social stimulation can be reinforced), and in the fourth was the work overload for the nursing team.

CONCLUSIONS

The experiences of the nursing team in the prevention and treatment of delirium in critically ill patients highlight that communication allows an approach to the patient as a human being immersed in a reality, with a personal history, needs and preferences. Therefore, family members must be involved in these scenarios, as they can complement and support nursing care.

Evaluating the Cost-Effectiveness of the ABCDE Bundle: Impact of Bundle Adherence on Inpatient and 1-Year Mortality and Costs of Care

OBJECTIVES

Growing evidence supports the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle processes as improving a number of short- and long-term clinical outcomes for patients requiring ICU care. To assess the cost-effectiveness of this intervention, we determined the impact of ABCDE bundle adherence on inpatient and 1-year mortality, quality-adjusted life-years, length of stay, and costs of care.

DESIGN

We conducted a 2-year, prospective, cost-effectiveness study in 12 adult ICUs in six hospitals belonging to a large, integrated healthcare delivery system.

SETTING

Hospitals included a large, urban tertiary referral center and five community hospitals. ICUs included medical/surgical, trauma, neurologic, and cardiac care units.

PATIENTS

The study included 2,953 patients, 18 years old or older, with an ICU stay greater than 24 hours, who were on a ventilator for more than 24 hours and less than 14 days.

INTERVENTION

ABCDE bundle.

MEASUREMENTS AND MAIN RESULTS

We used propensity score-adjusted regression models to determine the impact of high bundle adherence on inpatient mortality, discharge status, length of stay, and costs. A Markov model was used to estimate the potential effect of improved bundle adherence on healthcare costs and quality-adjusted life-years in the year following ICU admission. We found that patients with high ABCDE bundle adherence (≥ 60%) had significantly decreased odds of inpatient mortality (odds ratio 0.28) and significantly higher costs ($3,920) of inpatient care. The incremental cost-effectiveness ratio of high bundle adherence was $15,077 (95% CI, $13,675-$16,479) per life saved and $1,057 per life-year saved. High bundle adherence was associated with a 0.12 increase in quality-adjusted life-years, a $4,949 increase in 1-year care costs, and an incremental cost-effectiveness ratio of $42,120 per quality-adjusted life-year.

CONCLUSIONS

The ABCDE bundle appears to be a cost-effective means to reduce in-hospital and 1-year mortality for patients with an ICU stay.

Environmental Factors Affecting Early Mobilization and Physical Disability Post-Intensive Care: An Integrative Review Through the Lens of the World Health Organization International Classification of Functioning, Disability, and Health

BACKGROUND

Early mobilization (EM) is one of few potential protective factors associated with reduced physical disability post-intensive care (PD PIC). However, only 45% of intensive care units (ICUs) in the United States routinely practice EM despite its recognized benefits.

OBJECTIVES

To analyze the evidence on the relationship between critical care EM, PD PIC, and environmental factors, using the theoretical lens of the World Health Organization's (WHO's) International Classification of Functioning, Disability, and Health (ICF).

METHOD

The Whittemore and Knafl methodology for integrative reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines were followed. Qualitative, quantitative, and mixed-methods studies (n = 38) that evaluated EM and 1 or more domains of the WHO ICF were included. Quality was appraised using the Mixed-Methods Appraisal Tool. Study characteristics were evaluated for common themes and relationships. The ICF domains and subdomains pertaining to each study were synthesized.

RESULTS

Early mobilization was related to improved functioning on the disability continuum of the WHO ICF. Early mobilization was influenced by several WHO ICF environmental factors. Dedicated physical and occupational therapy teams in the ICU, interdisciplinary rounds, and positive family and staff perception of EM facilitated intervention delivery. However, poor staffing levels, negative unit culture, perceived workload burden, and lack of equipment, education, and financial support impeded delivery of EM.

DISCUSSION

Early mobilization is a promising intervention that may reduce PD PIC. However, environmental factors negatively influence delivery of EM in the ICU. Several gaps in EM research limit its acceptability in ICU practice. Existing EM research is challenged by poor methodological quality. Further study is necessary to better understand the role of EM on PD PIC and improve patient outcomes following critical illness.

L’autonomie décisionnelle d’infirmières de soins intensifs lors du sevrage de la ventilation mécanique : une analyse de concept

Nurses have a leading role in weaning patients from mechanical ventilation (WMV) given their constant presence and their continuous monitoring. To promote proper WMV, nurses must exercise autonomy and be involved in decision-making. However, in certain care contexts, there is little involvement of nurses. The purpose of this text is to establish the characteristics of the concept of autonomous decision-making applied to nursing during WMV. An analysis of this concept was carried out according to the evolutionary method of Rodgers. The identification of the attributes, antecedents, and consequences made it possible to note ambiguity in the definition of this concept. Nurses use autonomous decision-making for the execution of assigned tasks and when they make decisions according to a pre-prescribed decision-making algorithm. Significant foundations for the decision-making autonomy of critical care nurses during WMV emerged from this analysis&#160;: scope of practice, in-depth knowledge of the patient, and commitment to the success of WMV. Participation in interdependent decision-making allows nurses to bring the patient&#8217;s perspective into decisions. Avenues of reflection have also emerged, including decisions based on evidence to provide new avenues for autonomous decision-making.

Pre-existing mental health disorders in patients admitted to the intensive care unit: A systematic review and meta-analysis of prevalence

AIMS

To determine the reported prevalence rate of pre-existing mental health disorders in patients admitted to adult ICUs and identify the most commonly occurring types of these disorders.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Five electronic databases were searched from 1 January 2000 -15 April 2020. Google Scholar was used to perform forwards citation searching.

METHODS

This review was conducted in line with the PRISMA guidelines and protocol registered with PROSPERO CRD42020181818. Meta-analyses were performed using the quality effects model to calculate weighted pooled prevalence estimates and heterogeneity was tested using the I² statistic.

RESULTS

Seven articles were included in the final review and meta-analysis (143,179 participants). Identified prevalence rates varied considerably, ranging from 6.2-28.0%, reflecting variation in each study's clinical context, as well as different patient selection and identification methodologies. The pooled prevalence rate of all pre-existing mental health disorders was 19.4% (95% CI 8.9-32.6%). Depression was the most common subtype, accounting for an estimated 60.5% (95% CI 54.4-66.5%) of identified mental health disorders. All analyses showed significant heterogeneity with I²  > 95%.

CONCLUSION

Approximately 19% of adult ICU patients have a history of a mental health disorder, most commonly depression. Further research is needed to improve the accuracy of this estimate as well as determine the best identification method.

IMPACT

This study has demonstrated that patients with pre-existing mental health disorders, particularly depression, constitute a significant subgroup in ICU. Given that the presence of a pre-existing mental health disorder appears to confer an increased mortality risk following ICU discharge, clinicians need to be made aware of this group of patients to provide additional support. Further research is needed to more accurately quantify this vulnerable group and establish methods to enable clinicians to readily identify and refer these patients for appropriate follow-up treatment.

Accuracy of delirium assessments in critically ill children: A prospective, observational study during routine care

OBJECTIVES

The objectives of this study was to explore the accuracy of the Cornell Assessment for Pediatric Delirium (CAP-D), Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), and Preschool Confusion Assessment Method for the Intensive Care Unit (psCAM-ICU) when implemented in routine care as delirium screening tools, and to assess patient characteristics and clinical variables that may affect their validity.

DESIGN

This is a prospective observational study.

SETTING

The study was conducted in a 36-bed, mixed paediatric intensive care unit (PICU) at an Australian tertiary hospital.

PATIENTS

The study included critically ill children developmentally aged 6 months to 17 years, with a PICU length of stay >18 h.

INTERVENTIONS

No interventions were provided in the study.

MEASUREMENTS AND MAIN RESULTS

Patients were screened for delirium by their bedside nurse (CAP-D and pCAM-ICU/psCAM-ICU) once daily, for up to 5 d. Delirium status identified using screening instruments was compared with delirium diagnosis using the diagnostic criteria for delirium (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition). In this sample, the CAP-D retained its high sensitivity (91.3%) and good specificity (75.2%), whereas the psCAM-ICU and pCAM-ICU had moderate sensitivity (58.8% and 75.0%, respectively) and excellent specificity (89.8% and 84.9%, respectively). There was moderate agreement between the CAP-D and the psCAM-ICU (κ = 0.52, p < .001) and good agreement between the CAP-D and the pCAM-ICU (κ = 0.80, p < .01).

CONCLUSIONS

Although the CAP-D, psCAM-ICU, and pCAM-ICU all appear promising in their validation studies, when implemented in routine care, their performance can be variable. The CAP-D performed well in routine clinical practice, but follow-up diagnosis is required to confirm delirium. The psCAM-ICU and pCAM-ICU both provide valuable, objective assessments of delirium in critically ill children; however, further evaluation of their implementation in routine clinical practice is needed.

A multisite study of multidisciplinary ICU team member beliefs toward early mobility

BACKGROUND

Early mobility is underutilized in critical care.

OBJECTIVE

Describe multidisciplinary intensive care unit (ICU) providers beliefs about the conduct of early mobility during critical illness.

METHODS

A 7-item elicitation survey was administered to a multidisciplinary sample of ICU team members. We conducted independent thematic analysis of n = 95 surveys.

RESULTS

Analysis resulted in three themes: immediate risk vs. long-term reward conflict, nurse is the initiator and coordinator of early mobilization, and situational factors. Staffing was the primary facilitator and barrier to early mobility. Enablers included protection from complications of hospitalization, reduced hospital length of stay, and improved patient morale. Barriers strongly revolved around team member risk aversion (e.g., falls, hemodynamic instability, line dislodgment). Nurses were equally identified as positive and negative referents for early mobility.

CONCLUSIONS

Strong positive and negative attitudinal beliefs were elicited. Early mobility is a protective behavior that requires sufficient numbers of trained staff and equipment.

Study protocol for a prospective randomised double-blind placebo-controlled clinical trial investigating a Better Outcome with Melatonin compared to Placebo Administered to normalize sleep-wake cycle and treat hypoactive ICU Delirium: the Basel BOMP-AID study

INTRODUCTION

Delirium is frequently observed in the intensive care unit (ICU) population, in particular. Until today, there is no evidence for any reliable pharmacological intervention to treat delirium. The Basel BOMP-AID (Better Outcome with Melatonin compared to Placebo Administered to normalize sleep-wake cycle and treat hypoactive ICU Delirium) randomised trial targets improvement of hypoactive delirium therapy in critically ill patients and will be conducted as a counterpart to the Basel ProDex Study (Study Protocol, BMJ Open, July 2017) on hyperactive and mixed delirium. The aim of the BOMP-AID trial is to assess the superiority of melatonin to placebo for the treatment of hypoactive delirium in the ICU. The study hypothesis is based on the assumption that melatonin administered at night restores a normal circadian rhythm, and that restoration of a normal circadian rhythm will cure delirium.

METHODS AND ANALYSIS

The Basel BOMP-AID study is an investigator-initiated, single-centre, randomised controlled clinical trial for the treatment of hypoactive delirium with the once daily oral administration of melatonin 4 mg versus placebo in 190 critically ill patients. The primary outcome measure is delirium duration in 8-hour shifts. Secondary outcome measures include delirium-free days and death at 28 days after study inclusion, number of ventilator days, length of ICU and hospital stay, and sleep quality. Patients will be followed after 3 and 12 months for activities of daily living and mortality assessment. Sample size was calculated to demonstrate superiority of melatonin compared with placebo regarding the duration of delirium. Results will be presented using an intention-to-treat approach.

ETHICS AND DISSEMINATION

This study has been approved by the Ethics Committee of Northwestern and Central Switzerland and will be conducted in compliance with the protocol, the current version of the Declaration of Helsinki, the International Conference on Harmonisation (ICH) of technical requirements for registration of pharmaceuticals for human use; Good Clinical Practice (GCP) or ISO EN 14155 (as far as applicable), as well as all national legal and regulatory requirements. Study results will be presented in international conferences and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03438526.

PROTOCOL VERSION

Clinical Study Protocol Version 3, 10.03.2019.

Delirium prevalence and prevention in patients with acute brain injury: A prospective before-and-after intervention study

OBJECTIVES

Knowledge regarding delirium prevention in patients with acute brain injury remains limited. We tested the hypothesis that an intervention bundle which targeted sedation, sleep, pain, and mobilisation would reduce delirium in patients with acute brain injury.

DESIGN

A prospective before-after intervention study: a five-month phase of standard care was followed by a six-month intervention phase.

SETTING

The neuro-intensive care unit, University Hospital of Copenhagen, Denmark.

MAIN OUTCOME MEASURES

The Intensive Care Delirium Screening Checklist was used to detect delirium. Primary outcome was delirium duration; secondary outcomes were delirium prevalence, ICU length of stay and one year mortality.

RESULTS

Forty-four patients were included during the standard care phase, and 50 during the intervention phase. Delirium was present in 90% of patients in the standard care group and 88% in the intervention group (p = 1.0), and time with delirium was 4 days vs 3.5 days (p = 0.26), respectively. Also, ICU length of stay (13 vs. 10.5 days (p = 0.4)) and the one year mortality (21% vs 12% (p = 0.38))) were similar between groups.

CONCLUSION

We found a high prevalence of delirium in patients with acute brain injury. The intervention bundle did not significantly reduce prevalence or duration of delirium, ICU length of stay or one year mortality.

Optimizing energy expenditure and oxygenation toward ventilator tolerance is associated with lower ventilator and intensive care unit days

BACKGROUND

We hypothesize that if both energy expenditure and oxygenation are optimized (EEOO) toward ventilator tolerance, this would provide patients with the best condition to be liberated from the ventilator. We defined ventilator tolerance as having a respiratory quotient value between 0.7 and 1.0 while maintaining saturations above 98% with FIO2 70% or less and a normal respiratory rate without causing disturbances to the patient's pH.

METHODS

This is a single-institution prospective cohort study of ventilator dependent patients within a closed trauma intensive care unit (ICU). The study period was over 52 months. A total of 1,090 patients were part of the primary analysis. The test group (EEOO) was compared to a historical cohort, comparing 26 months in each study group. The primary outcome of this study was number of ventilator days. Secondary outcomes included in-hospital mortality, ICU length of stay (LOS), overall hospital length of stay, tracheostomy rates, reintubation rates, and in-hospital complication rates, such as pneumonia and Acute Respiratory Distress Syndrome (ARDS) ARDS. Both descriptive and multivariable regression analyses were performed to compare the effects of the EEOO protocol with our standard protocols alone.

RESULTS

The primary outcome of number of ventilator days was significantly shorter the EEOO cohort by nearly 3 days. This was significant even after adjustment for age, sex, race, comorbidities, nutrition type, and injury severity, (4.3 days vs. 7.2 days, p = 0.0001). The EEOO cohort also had significantly lower ICU days, hospital days, and overall complications rates.

CONCLUSION

Optimizing the patient's nutritional regimen to ventilator tolerance and optimizing oxygenation by means of targeted pulmonary mechanics and inspired FIO2 may be associated with lower ventilator and ICU days, as well as overall complication rates.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

The Experience of Acute Mechanical Ventilation From the Patient's Perspective

BACKGROUND

The Pain, Agitation, and Delirium guidelines influenced practice to support targeted, light sedation for the mechanically ventilated patient. This practice is associated with improved clinical outcomes, but it remains unclear how it impacts the patient experience.

OBJECTIVE

The objective was to determine the pervasive patient experience components and how the experience may have been influenced by targeted, light sedation practices.

METHODS

A prospective observational study using mixed methodology and a convenience sample was conducted after institutional review board approval was obtained. Inclusion criteria were the following: acute mechanical ventilation of less than 14 days, 18 years or older and able to provide consent, English speaking, and delirium-free. Exclusion criteria were the presence of delirium or intravenous opioids/sedatives within 24 hours prior to the interview. The quantitative component included simple yes or no questions and identification of quantitative adjectives describing the mechanical ventilation experience. Every 10th patient was invited to participate in an expanded qualitative interview.

RESULTS

Data were collected for 12 months with a total sample size of 130 patients participating in the quantitative component and a subset of 15 patients also participating in the qualitative interview. Sixty percent of the total sample consisted of cardiothoracic surgery patients, and 40% were mixed intensive care unit patient populations. Descriptive statistics include the following averaged values: Richmond Agitation Sedation Scale scores -1.7 throughout mechanical ventilation, aged 59.9 years, days mechanically ventilated 1.4, intensive care unit length of stay 4.6 days, and Acute Physiology and Chronic Health Evaluation II score 16.1. The most significant finding was that 56.2% of patients who could not communicate reported feeling afraid, whereas 32.5% of those who could communicate reported feeling afraid (P < .027). The themes identified in the qualitative component of the study reinforced these quantitative findings; 10 of the 15 patients interviewed reported experiencing fear, and all of the patients reported issues with communication.

DISCUSSION

The clinical implications of this research study primarily affect critical care nursing. Changes in nursing practice can address these findings to improve and more effectively acknowledge the patient experience.

Factors Associated With Nurses' Knowledge of and Perceived Value in Evidence-Based Practices

BACKGROUND

Little is known about how the education and specialty certification of intensive care unit nurses influence patients' outcomes.

OBJECTIVE

To examine the relationships between critical care nurses' education level and specialty certification, their individual psychosocial beliefs about their place on the intensive care unit team (in relation to 3 factors: professional identity, self-efficacy, and role clarity), and their perceptions of evidence-based practices used in the intensive care unit.

METHODS

A cross-sectional survey was emailed to nurses in 12 adult intensive care units within 6 hospitals in a single, integrated health care system.

RESULTS

Of 268 respondents, 180 (71%) had a bachelor of science degree or higher, and 71 (26%) had critical care certification. Compared with noncertified nurses, certified nurses reported greater knowledge of spontaneous breathing trials (4.6 vs 4.4 on a 5-point scale, P = .03) and lung-protective ventilation (4.2 vs 3.9, P = .05). Certified nurses reported significantly higher self-efficacy (4.5 vs 4.3 on a 5-point scale, P = .001) and role clarity (4.4 vs 4.2, P = .05) than noncertified nurses. Certification was also associated with greater perceived value in specific practices (daily interruption of sedation: adjusted odds ratio 2.5 [95% CI, 1.0-6.3], P = .05; lung-protective ventilation: adjusted odds ratio, 1.9 [95% CI, 1.1-3.3], P = .03). Education level was not associated with greater knowledge of or perceived value in evidence-based practices.

CONCLUSIONS

Nursing specialty certification was associated with nurses' individual psychosocial beliefs and their perceptions of evidence-based practices in the intensive care unit, whereas education level was not. Supporting nurses in obtaining specialty certification could assist with the adoption of evidence-based practices as a means to improve quality of care in the intensive care unit.

Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ICU Liberation ABCDEF Bundle Improvement Collaborative

The ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment) improves intensive care unit patient-centered outcomes and promotes interprofessional teamwork and collaboration. The Society of Critical Care Medicine recently completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, multicenter, national quality improvement initiative that formalized dissemination and implementation strategies to promote effective adoption of the ABCDEF bundle. The purpose of this article is to describe 8 of the most frequently asked questions during the Collaborative and to provide practical advice from leading experts to other institutions implementing the ABCDEF bundle.

Effects of the ABCDE bundle on the prevention of post-intensive care syndrome: A retrospective study

AIM

To identify the effects of each domain of the early and modified ABCDE bundle on post-intensive care syndrome (PICS).

DESIGN

This is a retrospective study.

METHODS

We analysed the data from electronic medical records of 91 intensive care patients who received therapeutic interventions in stages, based on the early ABCDE bundle (admitted to the intensive care unit [ICU] from June - August 2013) and 94 patients who received interventions using a modified ABCDE bundle developed through continuous quality improvement activities (admitted to the ICU from June to August 2014).

RESULTS

In the ABC domain, the percentage of patients showing sedation levels of alertness and calmness increased significantly from 58.2% using the early ABCDE bundle to 72.4% using the modified ABCDE bundle. Coma prevalence decreased significantly from 45.1% using the early ABCDE bundle to 28.7% using the modified ABCDE bundle. In the E domain, the percentage of patients receiving early mobility interventions increased significantly from 11% using the early ABCDE bundle to 54.3% using the modified ABCDE bundle.

CONCLUSION

The ABCDE bundle in the ICU helped prevent PICS by reducing deep sedation and immobilization among intensive care patients. To effectively use the ABCDE bundle, it is necessary for institutions to develop suitable protocols for each constituent element and to test their effectiveness.

IMPACT

The ABCDE bundle was a suitable tool to support evidence-based practice in intensive care patients, including oversedation and immobilization, which is related to the prevention of PICS. Individual institutions will need to actively use the ABCDE bundle in the ICU, by developing protocols and testing their effectiveness.

Effects of early mobilization protocol performed after cardiac surgery on patient care outcomes

AIM

This study aimed to determine the effects of an early mobilization protocol performed in patients who underwent cardiac surgery on post-operative outcomes.

BACKGROUND

Post-operative complications are common in patients undergoing cardiac surgery. Early mobilization is recommended for patients who undergo cardiac surgery to prevent complications and achieve successful outcomes in post-operative care.

DESIGN

The study design was quasi-experimental with a control group.

METHODS

Participants were patients who underwent cardiac surgery between January and October 2015. The study included 102 patients (51 patients each in the experimental and control groups). The introductory characteristics form, the Richards-Campbell Sleep Questionnaire (RCSQ), duration of hospital stay (post-operatively), and development of a post-operative late complications form were used to collect data.

RESULTS

The study results revealed that patients in the experimental group had better improvement in RCSQ scores, shorter duration of hospitalization, and fewer late complications after surgery than patients in the control group.

CONCLUSION

Early mobilization is feasible in adult cardiac surgery patients and has significant benefits. More research is recommended into the effectiveness of early mobilization in different patient groups.

Medication Use and Risk of Delirium in Mechanically Ventilated Patients

One of the principal complications in patients in the intensive care unit, particularly in those receiving mechanical ventilation, is medication-induced delirium. The present study aimed to intensively analyze pharmaceutical factors affecting the development of delirium in mechanically ventilated patients using the electronic health records. The present study was designed as a retrospective case-control study. The delirium group included 500 mechanically ventilated patients. The non-delirium group included 2,000 patients who were hospitalized during the same period as the delirium group and received mechanical ventilation. A total of seven types of medications (narcotic analgesics, non-narcotic analgesics, psychopharmaceuticals, sleep aid medications, anticholinergics, steroids, and diuretics), conventionally used to manage mechanical ventilation, were found to be major risk factors associated with the occurrence of delirium. Since these medications are an integral part of managing mechanically ventilated patients, prudent protocol-based medication approaches are essential to decrease the risk of delirium.

Physical restraint in critical care units from the experience of doctors and nursing assistants: In search of an interdisciplinary interpretation

OBJECTIVES

The study aim was to explore the experience of doctors and nursing assistants in the management of physical restraint (PR) in critical care units.

METHOD

A multicentre phenomenological study that included 14 critical care units (CCU) in Madrid (Spain). The CCU were stratified according to their use of physical restraint: "frequently used" versus "seldom used". Three focus groups were formed: the first comprised nursing assistants from CCUs that frequently used physical restraint, the second comprised nursing assistants from CCUs that seldom used physical constraint, and the final group comprised doctors from both CCU subtypes. Sampling method: purposive.

DATA ANALYSIS

thematic content analysis. Data saturation was achieved.

RESULTS

Four principle themes emerged: 1) concept of safety and risk (patient safety versus the safety of the professional), 2) types of restraint, 3) professional responsibilities (prescription, recording, and professional roles) and 4) "zero restraint" paradigm. The conceptualisation regarding the use of physical contentions shows differences in some of the principal themes, depending on the type of CCU, in terms of policies, use and management of physical constraint (frequently used versus seldom used).

CONCLUSIONS

The real reduction in the use of physical restraint in CCU must be based on one crucial point: acceptance of the complexity of the phenomenon. The use of physical restraint observed in the different CCU is influenced by individual, group and organisational factors. These factors will determine how doctors and nursing assistants interpret safety and risk, the centre of care (patient or professional-centred care), the concept of restraint, professional responsibilities and interventions, interactions of the team and the leadership.

Qualitative descriptive study to explore nurses' perceptions and experience on pain, agitation and delirium management in a community intensive care unit

OBJECTIVES

The purpose of this study was to explore the experiences, beliefs and perceptions of intensive care unit (ICU) nurses on the management of pain, agitation and delirium (PAD) in critically ill patients.

DESIGN

A qualitative descriptive study.

SETTING

This study took place in a community hospital ICU located in a medium size Canadian city.

PARTICIPANTS

Purposeful sampling was conducted. Participants included full-time nurses working in the ICU. Forty-six ICU nurses participated.

METHODS

A total of five focus group sessions were held to collect data. There were one to three separate groups in each focus group session, with no more than seven participants in each group. There were 10 separate groups in total. A semistructured question guide was used. Thematic analysis method was adopted to analyse the data, and to search for emergent themes and patterns.

RESULTS

Three main themes emerged: (1) the professional perspectives on patient wakefulness state, (2) the professional perspectives on PAD management of critically ill patients and (3) the factors impacting PAD management. Nurses have different opinions on the optimal level of patient sedation and felt that many factors, including environmental, healthcare teams, patients and family members, can influence PAD management. This potentially leads to inconsistent PAD management in critically ill patients. The nurses also believed that PAD management requires a multidisciplinary approach including healthcare teams and patients' families.

CONCLUSIONS

Many external and internal factors contribute to the complexity of PAD management including the attitudes of nursing staff towards PAD. The themes emerged from this study suggested the need of a multifaceted and multidisciplinary quality improvement programme to optimise the management of PAD in the ICU.

Impacting Delirium in the Trauma ICU Utilizing the ICU Liberation Collaborative Benchmark Report

Delirium is a frequent complication of intensive care unit (ICU) admissions, manifesting as acute confusion with inattention and disordered thinking. Patients in the ICU who develop acute delirium are more likely to experience long-term disability and mortality. The Society of Critical Care Medicine published guidelines for the management of pain, agitation, and delirium (PAD) in the ICU in 2013. Based on these PAD guidelines, the ABCDEF bundle was created. Research is lacking on how adherence to the ABCDEF bundle elements impacts specific populations such as trauma patients. This represents a significant gap for patients whose multisystem injuries and comorbidities add a higher level of complexity to their care and outcomes. The medical ICU at a large community hospital participated in a 2-year quality improvement project as part of the Society of Critical Care Medicine's ICU Liberation Collaborative. However the organization's trauma ICU (TICU) was excluded from the study. The purpose of this study was to conduct a baseline assessment of trauma patient records to determine which bundle elements were already being applied in the TICU, and if the resources required for implementing the full ABCDEF bundle would be beneficial to the TICU patient outcomes. Benchmark data from the organization's participation in the ICU Liberation Collaborative quality improvement project served as the primary source of evidence. Analysis revealed strengths and opportunities for improvement. Incidence of delirium remained unchanged and far below national averages, indicating the need for further investigation into practices to verify this finding. An opportunity was identified to expand implementation of certain elements of the ABCDEF bundle in the trauma ICU. There is an opportunity for nurses to take the lead in improving patient outcomes. With improved education, evidence-based assessment tools, and best practice guidelines, nurses can help decrease the incidence of delirium by as much as 30%.

ABCDE and ABCDEF care bundles: A systematic review protocol of the implementation process in intensive care units

BACKGROUND

The awakening and breathing coordination of daily sedation and ventilator removal trials, delirium monitoring and management, and early mobility and exercise (ABCDE) and assessment, prevent and manage pain, both spontaneous awakening and spontaneous breathing trials, choice of analgesia and sedation, assess, prevent and manage delirium, early mobility and exercise, family engagement (ABCDEF) bundles are part of the science of the liberation of the intensive care unit (ICU). There are not enough studies that have evaluated the effectiveness and safety of the implementation of these bundles. This study will analyze the implementation process, estimate their effectiveness and safety, and identify barriers, facilitators and attitudes that have influenced the implementation process.

METHODS

Qualitative and quantitative studies will be eligible for our systematic review with adult patients who have been exposed to the implementation of the ABCDE or ABCDEF bundles compared to the usual care in the ICU. In order to search the implementation interventions of the bundles, we will search electronically: MEDLINE (PubMed); Excerpta Medica Database (Ovid); Cumulative Index to Nursing and Allied Health Literature (EBSCO); The Cochrane Library (Wiley); Web of Science; Virtual Health Library; and OpenGrey. We will not impose any language restrictions or publication status. Outcomes of interest include ICU and hospital length of stay; mechanical ventilation time; incidence and prevalence of delirium or coma; level of agitation and sedation; early mobilization; mortality in ICU and hospital; change in perception, attitude or behavior of the stakeholders; and change in knowledge of health professionals. The team of reviewers will independently screen search results, extract data from eligible studies, and assess risk of bias. Disagreements between the reviewers will be solved through consensus or arbitration by a third-party investigator. To assess the quality and risk of bias in randomized and quasi-randomized trials we will use the domain-based evaluation recommended by The Cochrane Handbook. Studies with other methodological designs will be evaluated using the Critical Appraisal Tools developed by The Joanna Briggs Institute. Other instruments may be used, if necessary.

RESULTS

The evidence derived from this study will increase the knowledge of effectiveness and safety of the implementation process of ABCDE and ABCDEF bundles.

CONCLUSION

The results could guide patients and healthcare practitioners by helping to facilitate evidence-based shared care decision making.

PROTOCOL REGISTRATION

PROSPERO CRD42019121307.

Intervention fidelity in postintensive care follow-up consultations at ten sites in the RAPIT-trial: A mixed-methods evaluation

AIM

The aim of the study was to evaluate intervention fidelity of nurses' delivery of the RAPIT recovery program for postintensive care patients.

BACKGROUND

Interventions addressing patient problems after intensive care lack description of the process of delivery and the evidence of their effectiveness. This is needed to understand how these interventions work.

DESIGN

Multistage intervention framework in a mixed-methods design. Intervention fidelity strategies were assessed for intervention design, training, delivery, receipt, and enactment with quantitative and qualitative methods inspired by the Medical Research Council and the National Institutes of Health Fidelity Framework.

METHODS

Data collection was embedded in a multicenter randomized controlled trial to explore intervention fidelity of a recovery program (December 2012-February 2017). Ten Danish intensive care units participated in the RAPIT-trial including 386 patients and 27 nurses. Quantitative data covered training and delivery. Qualitative data explored design, quality of delivery, receipt, and enactment seen from nurses' and patients' perspectives. Data were analysed statistically and by systematic deductive-inductive thematic analysis.

FINDINGS

A framework for participatory enactment of a complex intervention was developed and demonstrated delivery with high consistent fidelity across sites. Low delivery doses and variations were related to the program, patient, provider nurses and context.

CONCLUSION

Our study provides insight into the process of intervention fidelity of a nurse-led postintensive care recovery program and potentially enables professionals to understand key factors in cross-site implementation. Although we demonstrate consistent delivery and variations suggest that some patients may benefit more than others.

The Life Course Health Development Model: A theoretical research framework for paediatric delirium

AIMS AND OBJECTIVES

To create a framework for future research through application and critique of the Life Course Health Development Model to the phenomenon of paediatric delirium.

BACKGROUND

Delirium in the paediatric intensive care unit is associated with increased duration of mechanical ventilation, length of stay and mortality. Nurses are uniquely positioned at the bedside to identify, prevent and treat delirium. An understanding of the potential long-term consequences of paediatric delirium is necessary to provide impetus for nursing research and practice change. The Life Course Health Development Model is a valuable tool when considering the multiple mechanisms and processes through which the experience of delirium could affect a child's life trajectory.

DESIGN

Critical review of the literature through application and critique of the Life Course Health Development Model in the context of paediatric delirium. Gaps in the current understanding of paediatric delirium, as well as future directions for research and practice, are discussed.

METHODS

The seven core principles of the model are considered in the context of paediatric delirium. Each of the principles has the potential to further understanding of paediatric delirium and identify areas for future inquiry. This discussion leads to a critique of the ability of the model to lead future research and practice change.

CONCLUSIONS

The Life Course Health Development Model depicts a process in which the acute and severe stress of critical illness leads to maladaptive neurologic changes that contribute to the development of delirium and impair a child's life trajectory.

RELEVANCE TO CLINICAL PRACTICE

By emphasising the potential lifelong consequences for critically ill children who experience delirium, this application of the Life Course Health Development Model will stimulate discussion, research and practice change among paediatric clinicians and researchers.