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Hamadeh S, Willetts G, Garvey L. Pain management interventions of the non-communicating patient in intensive care: What works for whom and why? A rapid realist review. J Clin Nurs 2024; 33:2050-2068. [PMID: 38450782 DOI: 10.1111/jocn.17065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/19/2023] [Accepted: 01/23/2024] [Indexed: 03/08/2024]
Abstract
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.
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Affiliation(s)
- Samira Hamadeh
- Institute of Health and Wellbeing, Federation University, Churchill, Victoria, Australia
| | - Georgina Willetts
- Institute of Health and Wellbeing, Federation University, Churchill, Victoria, Australia
| | - Loretta Garvey
- Assessment Transformation, Federation University, Berwick, Victoria, Australia
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McCudden A, Valdivia HR, Di Gennaro JL, Berika L, Zimmerman J, Dervan LA. Barriers to Implementing the ICU Liberation Bundle in a Single-center Pediatric and Cardiac ICUs. J Intensive Care Med 2024; 39:558-566. [PMID: 38105529 DOI: 10.1177/08850666231220558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Abstract
Objectives: The intensive care unit (ICU) Liberation "ABCDEF" Bundle improves outcomes in critically ill adults. We aimed to identify common barriers to Pediatric ICU Liberation Bundle element implementation, to describe differences in barrier perception by ICU staff role, and to describe changes in reported barriers over time. Study Design: A 91-item survey was developed based on existing literature, iteratively revised, and tested by the PICU Liberation Committee at Seattle Children's Hospital, a tertiary free-standing academic children's hospital. Voluntary surveys were administered electronically to all ICU staff twice over 4-week periods in 2017 and 2020. Survey Respondents: 119 (2017) and 163 (2020) pediatric and cardiac ICU staff, including nurses (n = 142, 50%), respiratory therapists (RTs) (n = 46, 16%), attending and fellow physicians, hospitalists, and advanced practice providers (APPs) (n = 62, 22%), physical, occupational, and speech-language pathology therapists (n = 25, 9%), and pharmacists (n = 7, 2%). Measurements and Main Results: Respondents widely agreed that increased workload (78%-100% across roles), communication (53%-84%), and lack of RT-directed ventilator weaning (68%-88%) are barriers to implementation. Other barriers differed by role. In 2020, nurses reported liability (59%) and personal injury (68%) concerns, patient severity of illness (24%), and family discomfort with ICU liberation practices (41%) more frequently than physicians and APPs (16%, 6%, 8%, and 19%, respectively; P < .01 for all). Between 2017 and 2020, some barriers changed: RTs endorsed discomfort with early mobilization less frequently (50% vs 11%, P = .028) and nurses reported concern for patient harm less frequently (51% vs 24%, P = .004). Conclusions: Implementation efforts aimed at addressing known barriers, including educating staff on the safety of early mobility, considering respiratory therapist-directed ventilator weaning, and standardizing interdisciplinary discussion of Pediatric ICU Liberation Bundle elements, will be needed to overcome barriers and improve ICU Liberation Bundle implementation.
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Affiliation(s)
- Anna McCudden
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Hector R Valdivia
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Jane L Di Gennaro
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Lina Berika
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Jerry Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
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Smith LM, Campbell D, Prush N, Trojanowski S, Sherman E, Yost E. Implementation and Mixed-Methods Assessment of an Early Mobility Interprofessional Education Simulation. Dimens Crit Care Nurs 2024; 43:158-167. [PMID: 38564459 DOI: 10.1097/dcc.0000000000000634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Extended periods of bed rest and mechanical ventilation (MV) have devastating effects on the body. BACKGROUND Early mobility (EM) for patients in respiratory failure is safe and feasible, and an interprofessional team is recommended. Using simulation to train EM skills improves student confidence. The purpose of this study was to enable health care student collaboration as an interprofessional team in providing safe management and monitoring during an EM simulation for a patient requiring MV. METHODS Nursing (n = 33), respiratory (n = 7), occupational (n = 24), and physical therapist students (n = 55) participated in an EM interprofessional education (IPE) simulation experience. A mixed-methods analytic approach was used with pre/post quantitative analysis of the Student Perceptions of Interprofessional Clinical Education-Revised, Version 2 instrument and qualitative analysis of students' guided reflection papers. RESULTS Pre/post surveys completion rate was 39.5% (n = 47). The Student Perceptions of Interprofessional Clinical Education-Revised, Version 2 instrument indicated a significant improvement (P = .037) in students' perceptions of interprofessional collaborative practice. Qualitative data showed a positive response to the EM simulation IPE. Themes reflected all 4 Interprofessional Education Collaborative competencies. DISCUSSION This study demonstrated improved perception of interprofessional collaborative practice and better understanding of the Interprofessional Education Collaborative competencies. CONCLUSION Students collaborated in the simulation-based IPE to provide EM for a patient requiring MV and reported perceived benefits of the experience.
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Taylor J, Wilcox ME. Physical and Cognitive Impairment in Acute Respiratory Failure. Crit Care Clin 2024; 40:429-450. [PMID: 38432704 DOI: 10.1016/j.ccc.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Recent research has brought renewed attention to the multifaceted physical and cognitive dysfunction that accompanies acute respiratory failure (ARF). This state-of-the-art review provides an overview of the evidence landscape encompassing ARF-associated neuromuscular and neurocognitive impairments. Risk factors, mechanisms, assessment tools, rehabilitation strategies, approaches to ventilator liberation, and interventions to minimize post-intensive care syndrome are emphasized. The complex interrelationship between physical disability, cognitive dysfunction, and long-term patient-centered outcomes is explored. This review highlights the need for comprehensive, multidisciplinary approaches to mitigate morbidity and accelerate recovery.
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Affiliation(s)
- Jonathan Taylor
- Division of Pulmonary, Critical Care and Sleep Medicine, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029, USA
| | - Mary Elizabeth Wilcox
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
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Takiguchi C, Inoue T. 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. Jpn J Nurs Sci 2024; 21:e12584. [PMID: 38273738 DOI: 10.1111/jjns.12584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/09/2023] [Accepted: 12/17/2023] [Indexed: 01/27/2024]
Abstract
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.
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Affiliation(s)
| | - Tomoko Inoue
- International University of Health and Welfare, Tokyo, Japan
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Choong K, Fraser DD, Al-Farsi A, Awlad Thani S, Cameron S, Clark H, Cuello C, Debigaré S, Ewusie J, Kennedy K, Kho ME, Krasevich K, Martin CM, Thabane L, Nanji J, Watts C, Simpson A, Todt A, Wong J, Xie F, Vu M, Cupido C. Early Rehabilitation in Critically ill Children: A Two Center Implementation Study. Pediatr Crit Care Med 2024; 25:92-105. [PMID: 38240534 DOI: 10.1097/pcc.0000000000003343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES To implement an early rehabilitation bundle in two Canadian PICUs. DESIGN AND SETTING Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2). PATIENTS All children under 18 years old admitted to the PICU were eligible for the intervention. INTERVENTIONS A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization. MEASUREMENTS AND MAIN RESULTS Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement. CONCLUSIONS A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.
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Affiliation(s)
- Karen Choong
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Douglas D Fraser
- Department of Medicine, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Ahmed Al-Farsi
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Saif Awlad Thani
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Saoirse Cameron
- Lawson Health Research Institute, Children's Hospital at London Health Sciences Center, London, ON, Canada
| | | | - Carlos Cuello
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Joycelyne Ewusie
- The Research Institute, Biostatistics Unit, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - Kevin Kennedy
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Michelle E Kho
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | | | - Claudio M Martin
- Department of Pediatrics, Division of Critical Care, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Lehana Thabane
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- The Research Institute, Biostatistics Unit, St. Joseph's Healthcare, Hamilton, ON, Canada
| | - Jasmine Nanji
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | | | | | | | | | - Feng Xie
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael Vu
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Cynthia Cupido
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
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Barr J, Downs B, Ferrell K, Talebian M, Robinson S, Kolodisner L, Kendall H, Holdych J. Improving Outcomes in Mechanically Ventilated Adult ICU Patients Following Implementation of the ICU Liberation (ABCDEF) Bundle Across a Large Healthcare System. Crit Care Explor 2024; 6:e1001. [PMID: 38250248 PMCID: PMC10798758 DOI: 10.1097/cce.0000000000001001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024] Open
Abstract
OBJECTIVES To measure how the ICU Liberation Bundle (aka ABCDEF Bundle or the Bundle) affected clinical outcomes in mechanically ventilated (MV) adult ICU patients, as well as bundle sustainability and spread across a healthcare system. DESIGN We conducted a multicenter, prospective, cohort observational study to measure bundle performance versus patient outcomes and sustainability in 11 adult ICUs at six community hospitals. We then prospectively measured bundle spread and performance across the other 28 hospitals of the healthcare system. SETTING A large community-based healthcare system. PATIENTS In 11 study ICUs, we enrolled 1,914 MV patients (baseline n = 925, bundle performance/outcomes n = 989), 3,019 non-MV patients (baseline n = 1,323, bundle performance/outcomes n = 1,696), and 2,332 MV patients (bundle sustainability). We enrolled 9,717 MV ICU patients in the other 28 hospitals to assess bundle spread. INTERVENTIONS We used evidence-based strategies to implement the bundle in all 34 hospitals. MEASUREMENTS AND MAIN RESULTS We compared outcomes for the 12-month baseline and bundle performance periods. Bundle implementation reduced ICU length of stay (LOS) by 0.5 days (p = 0.02), MV duration by 0.6 days (p = 0.01), and ICU LOS greater than or equal to 7 days by 18.1% (p < 0.01). Performance period bundle compliance was compared with the preceding 3-month baseline compliance period. Compliance with pain management and spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) remained high, and reintubation rates remained low. Sedation assessments increased (p < 0.01) and benzodiazepine sedation use decreased (p < 0.01). Delirium assessments increased (p = 0.02) and delirium prevalence decreased (p = 0.02). Patient mobilization and ICU family engagement did not significantly improve. Bundle element sustainability varied. SAT/SBT compliance dropped by nearly half, benzodiazepine use remained low, sedation and delirium monitoring and management remained high, and patient mobility and family engagement remained low. Bundle compliance in ICUs across the healthcare system exceeded that of study ICUs. CONCLUSIONS The ICU Liberation Bundle improves outcomes in MV adult ICU patients. Evidence-based implementation strategies improve bundle performance, spread, and sustainability across large healthcare systems.
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Affiliation(s)
- Juliana Barr
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Brenda Downs
- Critical Care, Emergency Services and Sepsis, CommonSpirit Health, Phoenix, AZ
| | - Ken Ferrell
- Data Science, CommonSpirit Health, Phoenix, AZ
| | - Mojdeh Talebian
- Data Science Department, CommonSpirit Health, Phoenix, AZ
- ICU and Pulmonary Services, Dignity Health, Sequoia Hospital, Redwood City, CA
| | - Seth Robinson
- ICU, Dignity Health, Woodland Memorial Hospital, Woodland, CA
| | - Liesl Kolodisner
- Quality Reporting and Information, CommonSpirit Health, Phoenix, AZ
| | - Heather Kendall
- Gordon and Betty Moore Foundation Grants, Care Management, Roseville, CA
| | - Janet Holdych
- Acute Care Quality, CommonSpirit Health, Glendale, CA
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Anthony Hawkins W, Darley A, Malcom DR, Smith SE, Sikora A, Bland CM, Hixon LM, Flowers G, Branan TN. Design and implementation considerations of experiential interprofessional share days for a new practitioner. Am J Health Syst Pharm 2024; 81:e12-e17. [PMID: 37772433 DOI: 10.1093/ajhp/zxad238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Indexed: 09/30/2023] Open
Affiliation(s)
- W Anthony Hawkins
- Department of Clinical and Administrative Pharmacy University of Georgia College of Pharmacy Albany, GA
- Department of Pharmacology and Toxicology Medical College of Georgia at Augusta University Albany, GA, USA
| | - Andrew Darley
- Division of Experience Programs University of Georgia College of Pharmacy Athens, GA, USA
| | - Daniel R Malcom
- Department of Pharmacy Practice Sullivan University College of Pharmacy and Health Sciences
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy University of Georgia College of Pharmacy Athens, GA, USA
| | - Andrea Sikora
- Department of Clinical and Administrative Pharmacy University of Georgia College of Pharmacy Augusta, GA
- Department of Pharmacy Augusta University Medical Center Augusta, GA, USA
| | - Christopher M Bland
- Department of Clinical and Administrative Pharmacy University of Georgia College of Pharmacy Savannah, GA
- St. Joseph's/Candler Health System Savannah, GA, USA
| | - Lauren M Hixon
- Department of Critical Care Phoebe Physician Group Albany, GA, USA
| | - Gaylynn Flowers
- Department of Nursing Piedmont Healthcare Covington, GA, USA
| | - Trisha N Branan
- Department of Clinical and Administrative Pharmacy University of Georgia College of Pharmacy Athens, GA, USA
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Dayton K, Hudson M, Lindroth H. Stopping Delirium Using the Awake-and-Walking Intensive Care Unit Approach: True Mastery of Critical Thinking and the ABCDEF Bundle. AACN Adv Crit Care 2023; 34:359-366. [PMID: 38033207 PMCID: PMC11019856 DOI: 10.4037/aacnacc2023159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Kali Dayton
- Kali Dayton is ICU Sedation and Mobility Consultant, Dayton ICU Consulting, Washington
| | - Mark Hudson
- Mark Hudson is an ICU survivor and patient advocate for improved ICU care; podcaster of the ICU Life and Recovery podcast; and a student at the School of Psychology and Counselling, The Open University, Milton Keynes, United Kingdom
| | - Heidi Lindroth
- Heidi Lindroth is a clinician-nurse scientist, Department of Nursing, Mayo Clinic, 200 1st St SW, Mayo Clinic, Rochester, MN, 55902 ; and an affiliate scientist, Center for Innovation and Implementation Science and the Center for Aging Research, Regenstrief Institute, School of Medicine, Indiana University, Indianapolis, Indiana
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10
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Bourgault AM. Historical Letters to the Editor Mirror Current Issues in Nursing. Crit Care Nurse 2023; 43:7-10. [PMID: 38035614 DOI: 10.4037/ccn2023950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Affiliation(s)
- Annette M Bourgault
- Annette Bourgault is Editor of Critical Care Nurse. She is an associate professor at the University of Central Florida in Orlando and a nurse scientist with Orlando Health. Dr Bourgault can be reached at
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Davis CL, Bjoring M, Hursh J, Smith S, Blevins C, Blackstone K, Nicholson E, Hoke T, Michel J, Noth I, Barros A, Enfield K. The Intensive Care Unit Bundle Board: A Novel Real-Time Data Visualization Tool to Improve Maintenance Care for Invasive Catheters. Appl Clin Inform 2023; 14:892-902. [PMID: 37666277 PMCID: PMC10651369 DOI: 10.1055/a-2165-5861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/14/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Critically ill patients are at greater risk of healthcare-associated infections (HAIs). The use of maintenance bundles helps to reduce this risk but also generates a rapid accumulation of complex data that is difficult to aggregate and subsequently act upon. OBJECTIVES We hypothesized that a digital display summarizing nursing documentation of invasive catheters (including central venous access devices, arterial catheters, and urinary catheters) would improve invasive device maintenance care and documentation. Our secondary objectives were to see if this summary would reduce the duration of problematic conditions, that is, characteristics associated with increased risk of infection. METHODS We developed and implemented a data visualization tool called the "Bundle Board" to display nursing observations on invasive devices. The intervention was studied in a 28-bed medical intensive care unit (MICU). The Bundle Board was piloted for 6 weeks in June 2022 and followed by a comparison phase, where one MICU had Bundle Board access and another MICU at the same center did not. We retrospectively applied tile color coding logic to prior nursing documentation from 2021 until the pilot phase to facilitate comparison pre- and post-Bundle Board release. RESULTS After adjusting for time, other quality improvement efforts, and nursing shift, multiple linear regression demonstrated a statistically significant improvement in the completion of catheter care and documentation during the pilot phase (p < 0.0001) and comparison phase (p = 0.002). The median duration of documented problematic conditions was significantly reduced during the pilot phase (p < 0.0001) and in the MICU with the Bundle Board (comparison phase, p = 0.027). CONCLUSION We successfully developed a data visualization tool that changed ICU provider behavior, resulting in increased completion and documentation of maintenance care and reduced duration of problematic conditions for invasive catheters in MICU patients.
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Affiliation(s)
- Claire Leilani Davis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Margot Bjoring
- Department of Quality and Performance Improvement, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Jordyn Hursh
- Department of Nursing, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Samuel Smith
- Department of Nursing, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Cheri Blevins
- Department of Nursing, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Kris Blackstone
- Department of Nursing, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Evie Nicholson
- Department of Quality and Performance Improvement, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Tracey Hoke
- Department of Quality and Performance Improvement, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Jonathan Michel
- Department of Quality and Performance Improvement, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Imre Noth
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Andrew Barros
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, United States
| | - Kyle Enfield
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, United States
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Grissom CK, Holubkov R, Carpenter L, Hanna B, Jacobs JR, Jones C, Knighton AJ, Leither L, Lisonbee D, Peltan ID, Winberg C, Wolfe D, Srivastava R. Implementation of coordinated spontaneous awakening and breathing trials using telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH): a type II hybrid effectiveness-implementation cluster-randomized trial. Implement Sci 2023; 18:45. [PMID: 37735443 PMCID: PMC10515061 DOI: 10.1186/s13012-023-01303-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/09/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Intensive care unit (ICU) patients on mechanical ventilation often require sedation and analgesia to improve comfort and decrease pain. Prolonged sedation and analgesia, however, may increase time on mechanical ventilation, risk for ventilator associated pneumonia, and delirium. Coordinated interruptions in sedation [spontaneous awakening trials (SATs)] and spontaneous breathing trials (SBTs) increase ventilator-free days and improve mortality. Coordination of SATs and SBTs is difficult with substantial implementation barriers due to difficult-to-execute sequencing between nurses and respiratory therapists. Telehealth-enabled remote care has the potential to overcome these barriers and improve coordinated SAT and SBT adherence by enabling proactive high-risk patient monitoring, surveillance, and real-time assistance to frontline ICU teams. METHODS The telehealth-enabled, real-time audit and feedback for clinician adherence (TEACH) study will determine whether adding a telehealth augmented real-time audit and feedback to a usual supervisor-led audit and feedback intervention will yield higher coordinated SAT and SBT adherence and more ventilator-free days in mechanically ventilated patients than a usual supervisor-led audit and feedback intervention alone in a type II hybrid effectiveness-implementation cluster-randomized clinical trial in 12 Intermountain Health hospitals with 15 ICUs. In the active comparator control group (six hospitals), the only intervention is the usual supervisor-led audit and feedback implementation. The telehealth-enabled support (TEACH) intervention in six hospitals adds real-time identification of patients eligible for a coordinated SAT and SBT and consultative input from telehealth respiratory therapists, nurses, and physicians to the bedside clinicians to promote adherence including real-time assistance with execution. All intubated and mechanically ventilated patients ≥ 16 years of age are eligible for enrollment except for patients who die on the day of intubation or have preexisting brain death. Based on preliminary power analyses, we plan a 36-month intervention period that includes a 90-day run-in period. Estimated enrollment in the final analysis is up to 9900 mechanically ventilated patients over 33 months. DISCUSSION The TEACH study will enhance implementation science by providing insight into how a telehealth intervention augmenting a usual audit and feedback implementation may improve adherence to coordinated SAT and SBT and increase ventilator-free days. TRIAL REGISTRATION Clinicaltrials.gov, NCT05141396 , registered 12/02/2021.
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Affiliation(s)
- Colin K Grissom
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA.
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT, USA.
- Critical Care Operations, Intermountain Health, Canyons Region, Murray, UT, USA.
| | - Richard Holubkov
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Lori Carpenter
- Respiratory Care, Intermountain Health, Canyons Region, Salt Lake City, UT, USA
| | - Bridgett Hanna
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Jason R Jacobs
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
| | - Christopher Jones
- Critical Care Operations, Intermountain Health, Canyons Region, Murray, UT, USA
| | - Andrew J Knighton
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Lindsay Leither
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
| | - Dee Lisonbee
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Ithan D Peltan
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT, 84107, USA
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Carrie Winberg
- Respiratory Care, Intermountain Health, Canyons Region, Salt Lake City, UT, USA
| | - Doug Wolfe
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
| | - Rajendu Srivastava
- Healthcare Delivery Institute, Intermountain Health, Salt Lake City, UT, USA
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
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13
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Dewan M, Tegtmeyer K, Stalets EL. Through the Looking-Glass Door. Pediatr Crit Care Med 2023; 24:425-426. [PMID: 37140334 DOI: 10.1097/pcc.0000000000003227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Maya Dewan
- All authors: Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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An Exploration of Critical Care Professionals' Strategies to Enhance Daily Implementation of the Assess, Prevent, and Manage Pain; Both Spontaneous Awakening and Breathing Trials; Choice of Analgesia and Sedation; Delirium Assess, Prevent, and Manage; Early Mobility and Exercise; and Family Engagement and Empowerment: A Group Concept Mapping Study. Crit Care Explor 2023; 5:e0872. [PMID: 36890874 PMCID: PMC9988323 DOI: 10.1097/cce.0000000000000872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
Abstract
The goals of this exploratory study were to engage professionals from the Society for Critical Care Medicine ICU Liberation Collaborative ICUs to: 1) conceptualize strategies to enhance daily implementation of the Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; and Family engagement and empowerment (ABCDEF) bundle from different perspectives and 2) identify strategies to prioritize for implementation. DESIGN Mixed-methods group concept mapping over 8 months using an online method. Participants provided strategies in response to a prompt about what was needed for successful daily ABCDEF bundle implementation. Responses were summarized into a set of unique statements and then rated on a 5-point scale on degree of necessity (essential) and degree to which currently used. SETTING Sixty-eight academic, community, and federal ICUs. PARTICIPANTS A total of 121 ICU professionals consisting of frontline and leadership professionals. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A final set of 76 strategies (reduced from 188 responses) were suggested: education (16 strategies), collaboration (15 strategies), processes and protocols (13 strategies), feedback (10 strategies), sedation/pain practices (nine strategies), education (eight strategies), and family (five strategies). Nine strategies were rated as very essential but infrequently used: adequate staffing, adequate mobility equipment, attention to (patient's) sleep, open discussion and collaborative problem solving, nonsedation methods to address ventilator dyssynchrony, specific expectations for night and day shifts, education of whole team on interdependent nature of the bundle, and effective sleep protocol. CONCLUSIONS In this concept mapping study, ICU professionals provided strategies that spanned a number of conceptual implementation clusters. Results can be used by ICU leaders for implementation planning to address context-specific interdisciplinary approaches to improve ABCDEF bundle implementation.
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Prendergast NT, Onyemekwu CA, Potter KM, Tiberio PJ, Turnbull AE, Girard TD. Agitation is a Common Barrier to Recovery of ICU Patients. J Intensive Care Med 2023; 38:208-214. [PMID: 36300248 PMCID: PMC10443676 DOI: 10.1177/08850666221134262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Importance: Agitation is common in mechanically ventilated ICU patients, but little is known about physician attitudes regarding agitation in this setting. Objectives: To characterize physician attitudes regarding agitation in mechanically ventilated ICU patients. Design, Setting, and Participants: We surveyed critical care physicians within a multicenter health system in Western Pennsylvania, assessing attitudes regarding agitation during mechanical ventilation and use of and confidence in agitation management options. We used quantitative clinical vignettes to determine whether agitation influences confidence regarding readiness for extubation. We sent our survey to 332 critical care physicians, of whom 80 (24%) responded and 69 were eligible (had cared for a mechanically ventilated patient in the preceding three months). Main Outcomes and Measures: Respondent confidence in patient readiness for extubation (0-100%, continuous) and frequency of use and confidence in management options (1-5, Likert). Results: Of 69 eligible responders, 61 (88%) agreed agitation is common and 49 (71%) agreed agitation is a barrier to extubation, but only 27 (39%) agreed their approach to agitation is evidence-based. Attitudes regarding agitation did not differ much by practice setting or physician demographics, though respondents working in medical ICUs were more likely (P = .04) and respondents trained in surgery or emergency medicine were less likely (P = .03) than others to indicate that agitation is an extubation barrier. Fifty-three (77%) respondents reported they frequently use non-pharmacologic measures to treat agitation, and 42 (70%) of those who reported they used non-pharmacologic measures during the prior 3 months indicated confidence in their effectiveness. In responses to clinical vignettes, confidence in patient's readiness for extubation was significantly lower if the patient was agitated (P < .001) or tachypneic (P < .001), but the presence of both agitation and tachypnea did not reduce confidence compared with tachypnea alone (P = .24). Conclusions and Relevance: Most critical care physicians consider agitation during mechanical ventilation a common problem and agreed that agitation is a barrier to extubation. Treatment practice varies widely.
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Affiliation(s)
- Niall T Prendergast
- Division of Pulmonary, Allergy, and Critical Care Medicine in the Department of Medicine, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chukwudi A Onyemekwu
- Division of Pulmonary, Allergy, and Critical Care Medicine in the Department of Medicine, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kelly M Potter
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center in the Department of Critical Care Medicine, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Perry J Tiberio
- Division of Pulmonary, Allergy, and Critical Care Medicine in the Department of Medicine, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alison E Turnbull
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center in the Department of Critical Care Medicine, 12317University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Boehm LM, Mart MF, Dietrich MS, Work B, Wilson WT, Walker G, Piras SE. Effects of social influence and implementation climate and leadership on nurse-led early mobility behaviours in critical care. BMJ Open Qual 2022; 11:bmjoq-2022-001885. [PMID: 35697358 PMCID: PMC9196169 DOI: 10.1136/bmjoq-2022-001885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/31/2022] [Indexed: 11/04/2022] Open
Abstract
Introduction Early mobility (EM), initiating and advancing physical activity in the earliest days of critical illness, has been described as the most difficult component of the ABCDEF bundle to implement and coordinate. Successful implementation of EM in clinical practice requires multiple targeted implementation strategies. Objective Describe the associations of nurses’ EM attitudes, subjective norms, perceived behavioural control, intention, and implementation climate and leadership with self-reported and documented EM behaviour in the intensive care unit (ICU). Design This was a two-site, descriptive, cross-sectional study to explore nurses’ perception of the factors influencing EM adherence. Setting Three ICUs (medical, surgical and cardiovascular) in an academic medical centre and two ICUs (medical/surgical and cardiovascular) in a regional medical centre in middle Tennessee. Patients Critically ill adults. Interventions None. Main outcome measures A 34-item investigator-developed survey, Implementation Leadership Scale, and Implementation Climate Scale were administered to ICU nurses. Survey development was informed by a Theory of Planned Behavior based elicitation study and implementation science frameworks. Results The academic medical centre had markedly lower EM documentation. We found no difference in nurses’ EM attitudinal beliefs, social influence, facilitators, and barriers at both sites. Nurses perceived moderate social influence to perform EM similarly across sites and considerable control over their ability to perform EM. We did note site differences for implementation climate and leadership and objective EM adherence with the regional community medical centre demonstrating statistically significant relationships of implementation climate and leadership with self-report and documented EM behaviours. Conclusions We identified contextual differences in implementation climate and leadership influence when comparing nurse EM behaviours. Streamlined documentation, leadership advocacy for interprofessional coordination and manpower support, and multicomponent context-based implementation strategies could contribute to better EM adherence.
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Affiliation(s)
- Leanne M Boehm
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Matthew F Mart
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mary S Dietrich
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Brittany Work
- The University of Tennessee at Chattanooga, Chattanooga, Tennessee, USA
| | | | | | - Susan E Piras
- Tennessee Technological University, Cookeville, Tennessee, USA
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Balas MC, Tan A, Pun BT, Ely EW, Carson SS, Mion L, Barnes-Daly MA, Vasilevskis EE. Effects of a National Quality Improvement Collaborative on ABCDEF Bundle Implementation. Am J Crit Care 2022; 31:54-64. [PMID: 34972842 PMCID: PMC9972543 DOI: 10.4037/ajcc2022768] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The ABCDEF bundle (Assess, prevent, and manage pain and Delirium; Both spontaneous awakening and breathing trials; Choice of analgesia/sedation; Early mobility; and Family engagement) improves intensive care unit outcomes, but adoption into practice is poor. OBJECTIVE To assess the effect of quality improvement collaborative participation on ABCDEF bundle performance. METHODS This interrupted time series analysis included 20 months of bundle performance data from 15 226 adults admitted to 68 US intensive care units. Segmented regression models were used to quantify complete and individual bundle element performance changes over time and compare performance patterns before (6 months) and after (14 months) collaborative initiation. RESULTS Complete bundle performance rates were very low at baseline (<4%) but increased to 12% by the end. Complete bundle performance increased by 2 percentage points (SE, 0.9; P = .06) immediately after collaborative initiation. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; P = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], P = .002), sedation assessment (9.1% [SE, 3.7%], P = .02), and family engagement (7.8% [SE, 3%], P = .02) and then increased monthly at the same speed as the trend in the baseline period. Performance rates were lowest for spontaneous awakening/breathing trials and early mobility. CONCLUSIONS Quality improvement collaborative participation resulted in clinically meaningful, but small and variable, improvements in bundle performance. Opportunities remain to improve adoption of sedation, mechanical ventilation, and early mobility practices.
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Affiliation(s)
- Michele C. Balas
- University of Nebraska Medical Center College of Nursing, Omaha, Nebraska
| | - Alai Tan
- Center for Research and Health Analytics, College of Nursing, The Ohio State University, Columbus, Ohio
| | - Brenda T. Pun
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, and at the Tennessee Valley Veterans Affairs Geriatric Research Education and Clinical Center, Nashville, Tennessee
| | - Shannon S. Carson
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Lorraine Mion
- Center of Healthy Aging, Self-Management and Complex Care, The Ohio State University College of Nursing
| | | | - Eduard E. Vasilevskis
- Division of General Internal Medicine and Public Health, Section of Hospital Medicine; the Center for Health Services Research; the Center for Quality Aging; and the Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, and a staff physician, Tennessee Valley Veterans Affairs Geriatric Research Education and Clinical Center
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18
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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. Crit Care Explor 2021; 3:e0525. [PMID: 34549188 DOI: 10.1097/cce.0000000000000525] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
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.
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19
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Schmidt LE, Patel S, Stollings JL. The pharmacist's role in implementation of the ABCDEF bundle into clinical practice. Am J Health Syst Pharm 2021; 77:1751-1762. [PMID: 32789461 DOI: 10.1093/ajhp/zxaa247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To summarize published data regarding implementation of the ABCDEF bundle, a multicomponent process for avoidance of oversedation and prolonged ventilation in intensive care unit (ICU) patients; discuss pertinent literature to support each bundle element; and discuss the role of the pharmacist in coordinating bundle elements and implementation of the ABCDEF bundle into clinical practice. SUMMARY Neuromuscular weakness and ICU-acquired weakness are common among critically ill patients and associated with significant cost and societal burdens. Recent literature supporting early liberation from mechanical ventilation and early mobilization has demonstrated improved short- and long-term outcomes. With expanded use of pharmacy services in the ICU setting, pharmacists are well positioned to advocate for best care practices in ICUs. A dedicated, interprofessional team is necessary for the implementation of the ABCDEF bundle in inpatient clinical practice settings. As evidenced by a number of studies, successful implementation of the ABCDEF bundle derives from involvement by motivated and highly trained individuals, timely completion of individual patient care tasks, and effective leadership to ensure proper implementation and ongoing support. Factors commonly identified by clinicians as barriers to bundle implementation in clinical practice include patient instability and safety concerns, lack of knowledge, staff concerns, unclear protocol criteria, and lack of interprofessional team care coordination. This narrative review discusses research on bundle elements and recommendations for application by pharmacists in clinical practice. CONCLUSIONS Despite the benefits associated with implementation of the ABCDEF bundle, evidence suggests that the recommended interventions may not be routinely used within the ICU. The pharmacist provides the expertise and knowledge for adoption of the bundle into everyday clinical practice.
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Affiliation(s)
- Lauren E Schmidt
- Department of Pharmacy, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Sneha Patel
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN.,Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN
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20
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Stollings JL, Kotfis K, Chanques G, Pun BT, Pandharipande PP, Ely EW. Delirium in critical illness: clinical manifestations, outcomes, and management. Intensive Care Med 2021; 47:1089-1103. [PMID: 34401939 PMCID: PMC8366492 DOI: 10.1007/s00134-021-06503-1] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 07/29/2021] [Indexed: 12/22/2022]
Abstract
Delirium is the most common manifestation of brain dysfunction in critically ill patients. In the intensive care unit (ICU), duration of delirium is independently predictive of excess death, length of stay, cost of care, and acquired dementia. There are numerous neurotransmitter/functional and/or injury-causing hypotheses rather than a unifying mechanism for delirium. Without using a validated delirium instrument, delirium can be misdiagnosed (under, but also overdiagnosed and trivialized), supporting the recommendation to use a monitoring instrument routinely. The best-validated ICU bedside instruments are CAM-ICU and ICDSC, both of which also detect subsyndromal delirium. Both tools have some inherent limitations in the neurologically injured patients, yet still provide valuable information about delirium once the sequelae of the primary injury settle into a new post-injury baseline. Now it is known that antipsychotics and other psychoactive medications do not reliably improve brain function in critically ill delirious patients. ICU teams should systematically screen for predisposing and precipitating factors. These include exacerbations of cardiac/respiratory failure or sepsis, metabolic disturbances (hypoglycemia, dysnatremia, uremia and ammonemia) receipt of psychoactive medications, and sensory deprivation through prolonged immobilization, uncorrected vision and hearing deficits, poor sleep hygiene, and isolation from loved ones so common during COVID-19 pandemic. The ABCDEF (A2F) bundle is a means to facilitate implementation of the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS) Guidelines. In over 25,000 patients across nearly 100 institutions, the A2F bundle has been shown in a dose-response fashion (i.e., greater bundle compliance) to yield improved survival, length of stay, coma and delirium duration, cost, and less ICU bounce-backs and discharge to nursing homes.
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Affiliation(s)
- Joanna L Stollings
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA.
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Katarzyna Kotfis
- Department Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Gerald Chanques
- Department of Anaesthesia and Critical Care Medicine, Saint Eloi Hospital, Montpellier University Hospital Center, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Brenda T Pun
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pratik P Pandharipande
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, 1211 Medical Center Drive, B-131 VUH, Nashville, TN, 37232-7610, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, Nashville, TN, USA
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21
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Barr J, Paulson SS, Kamdar B, Ervin JN, Lane-Fall M, Liu V, Kleinpell R. The Coming of Age of Implementation Science and Research in Critical Care Medicine. Crit Care Med 2021; 49:1254-1275. [PMID: 34261925 PMCID: PMC8549627 DOI: 10.1097/ccm.0000000000005131] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Juliana Barr
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Shirley S Paulson
- Regional Adult Patient Care Services, Kaiser Permanente, Northern California, Oakland, CA
| | - Biren Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego School of Medicine, La Jolla, CA
| | - Jennifer N Ervin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Meghan Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Vincent Liu
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, CA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
- Regional Adult Patient Care Services, Kaiser Permanente, Northern California, Oakland, CA
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California, San Diego School of Medicine, La Jolla, CA
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Division of Research, Kaiser Permanente Northern California, Santa Clara, CA
- Kaiser Permanente Medical Center, Santa Clara, CA
- Stanford University, Stanford, CA
- Hospital Advanced Analytics, Kaiser Permanente Northern California, Santa Clara, CA
- Vanderbilt University School of Nursing, Nashville, TN
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22
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Wilcox ME, Shankar-Hari M, McAuley DF. Delirium in COVID-19: can we make the unknowns knowns? Intensive Care Med 2021; 47:1144-1147. [PMID: 34191039 PMCID: PMC8244458 DOI: 10.1007/s00134-021-06467-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/21/2021] [Indexed: 12/28/2022]
Affiliation(s)
- M Elizabeth Wilcox
- Interdepartmental Division of Critical Care, University of Toronto and Consultant in Intensive Care Medicine at the Toronto Western Hospital, Toronto, Canada. .,Department of Medicine, Division of Respirology, Toronto Western Hospital, McLaughlin Wing 2-411M, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.
| | - Manu Shankar-Hari
- School of Immunology and Microbial Sciences, King's College London, London, UK.,Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Ireland.,Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Ireland
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23
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Huang JH, Wang TJ, Wu SF, Liu CY, Fan JY. Post-craniotomy fever and its associated factors in patients with traumatic brain injury. Nurs Crit Care 2021; 27:483-492. [PMID: 34145947 DOI: 10.1111/nicc.12640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 04/11/2021] [Accepted: 04/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Fever frequently occurs in patients with traumatic brain injury and can cause secondary damage to the brain. Critical care nurses play essential roles in assessing and managing fever in these patients. AIM The study aimed to (a) examine the fever causes in and condition of neurosurgical patients with traumatic brain injury in intensive care, (b) identify the factors associated with fever, and (c) determine the effects of fever on hospital stay and prognosis. STUDY DESIGN This study is a retrospective observational design. METHODS Data were collected through chart reviews of 93 traumatic brain injury patients admitted to a teaching hospital's intensive care unit for postoperative care. Fever was defined as at least one episode of body temperature >38°C. RESULTS Of the 93 patients, 76 developed a fever within 1-week post-craniotomy. Of these, 49 were infection-related and 27 were unexplained. Results of logistic regression showed that the preoperative Glasgow coma scale score (ß = -.323; P = .013) and length of intubation (ß = .480; P = .005) were the key predictors of unexplained post-craniotomy fever, and these two variables (ß = -.494; P < .001 and ß = .479; P = .006, respectively) were also the key predictors of infection-related fever. CONCLUSION A significant portion of patients developed a fever during the first post-craniotomy week. Patients with a lower pre-craniotomy Glasgow coma scale score and a longer intubation length were at a greater risk for both infection-related fever and unexplained fever. Patients with fever had a bad outcome score. RELEVANCE TO CLINICAL PRACTICE Critical care nurses should closely monitor traumatic brain injury patients' body temperatures and employ evidence-based infection prevention and control measures to minimize their infection risks. Respiratory care and intensive care unit Liberation Bundle should be reinforced to liberate these patients from mechanical ventilation and its associated complications.
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Affiliation(s)
- Jui-Hsia Huang
- Department of Nursing, Intensive Care Unit, Ten-Chan General Hospital, Taoyuan City, Taiwan
| | - Tsae-Jyy Wang
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Shu-Fang Wu
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Chieh-Yu Liu
- Department of Speech-Language Pathology and Audiology, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Jun-Yu Fan
- Department of Nursing, Chang Gung University of Science and Technology Linkou Campus, Taoyuan City, Taiwan
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24
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Abstract
Delirium, a form of acute brain dysfunction, is very common in the critically ill adult patient population. Although its pathophysiology is poorly understood, multiple factors associated with delirium have been identified, many of which are coincident with critical illness. To date, no drug or non-drug treatments have been shown to improve outcomes in patients with delirium. Clinical trials have provided a limited understanding of the contributions of multiple triggers and processes of intensive care unit (ICU) acquired delirium, making identification of therapies difficult. Delirium is independently associated with poor long term outcomes, including persistent cognitive impairment. A longer duration of delirium is associated with worse long term cognition after adjustment for age, education, pre-existing cognitive function, severity of illness, and exposure to sedatives. Interestingly, differences in prevalence are seen between ICU survivor populations, with survivors of acute respiratory distress syndrome experiencing higher rates of cognitive impairment at early follow-up compared with mixed ICU survivor populations. Although cognitive performance improves over time for some ICU survivors, impairment is persistent in others. Studies have so far been unable to identify patients at higher risk of long term cognitive impairment; this is an active area of scientific investigation.
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Affiliation(s)
- M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Timothy D Girard
- Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR, USA
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25
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Parker AM, Aldabain L, Akhlaghi N, Glover M, Yost S, Velaetis M, Lavezza A, Mantheiy E, Albert K, Needham DM. Cognitive Stimulation in an Intensive Care Unit: A Qualitative Evaluation of Barriers to and Facilitators of Implementation. Crit Care Nurse 2021; 41:51-60. [PMID: 33791762 DOI: 10.4037/ccn2021551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium in the intensive care unit is associated with poor patient outcomes. Recent studies support nonpharmacological therapy, including cognitive stimulation, to address delirium. Understanding barriers to cognitive stimulation implemented by nurses during clinical care is essential to translating evidence into practice. OBJECTIVE To use qualitative methods through a structured quality improvement project to understand nurses' perceived barriers to implementing a cognitive stimulation intervention in a medical intensive care unit. METHODS Data were collected through semistructured interviews with nurses in a medical intensive care unit. Data were categorized into themes by using thematic analysis and the Consolidated Framework for Implementation Research. During cognitive stimulation, nurses reviewed with patients a workbook of evidence-based tasks (focused on math, alertness, motor skills, visual perception, memory, problem-solving, and language). RESULTS The 23 nurses identified 62 barriers to and 26 facilitators of cognitive stimulation. These data were summarized into 12 barrier and 9 facilitator themes corresponding to the following Consolidated Framework for Implementation Research domains: Intervention Characteristics, Outer Setting, Inner Setting, and Characteristics of Individuals. Nurses also identified several facilitators within the Process domain. Patient-specific variables, including sedation, were the most frequently reported barriers. Other barriers included cognitive stimulation not being prioritized, nursing staff-related issues, documentation burden, and a lack of understanding of, or appreciation for, the evidence supporting cognitive stimulation. CONCLUSIONS Implementation of cognitive stimulation requires a multidisciplinary approach to address perceived barriers arising from the organization, context, and individuals associated with the intervention, as well as the intervention itself.
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Affiliation(s)
- Ann M Parker
- Ann M. Parker is an assistant professor, Division of Pulmonary and Critical Care Medicine, and a member of the Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University, Baltimore, Maryland
| | - Louay Aldabain
- Louay Aldabain is an internal medicine resident, Medstar Health, Baltimore, Maryland
| | - Narges Akhlaghi
- Narges Akhlaghi is a postdoctoral research fellow, Division of Pulmonary and Critical Care Medicine, and a member of the OACIS Research Group, Johns Hopkins University
| | - Mary Glover
- Mary Glover is a lead clinical nurse in the medical intensive care unit, Johns Hopkins Hospital, Baltimore, Maryland
| | - Stephanie Yost
- Stephanie Yost is a bedside nurse in the intensive care unit, University of Vermont Medical Center in Burlington, Vermont
| | - Michael Velaetis
- Michael Velaetis is a critical care physician assistant in the medical intensive care unit, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University
| | - Annette Lavezza
- Annette Lavezza is the acute care therapy manager, Johns Hopkins Hospital, and a member of the OACIS Research Group, Johns Hopkins University
| | - Earl Mantheiy
- Earl Mantheiy is a senior clinical program coordinator, Critical Care Physical Medicine and Rehabilitation Program, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine
| | - Kelsey Albert
- Kelsey Albert is a research program assistant, Critical Care Physical Medicine and Rehabilitation Program, and a member of the OACIS Research Group, Johns Hopkins University
| | - Dale M Needham
- Dale M. Needham is a professor, Division of Pulmonary and Critical Care Medicine, Department of Physical Medicine and Rehabilitation, School of Nursing, and a member of the OACIS Research Group, Johns Hopkins University
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ABCDEF Bundle and Supportive ICU Practices for Patients With Coronavirus Disease 2019 Infection: An International Point Prevalence Study. Crit Care Explor 2021; 3:e0353. [PMID: 33786432 PMCID: PMC7994035 DOI: 10.1097/cce.0000000000000353] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: To investigate implementation of evidence-based and supportive cares in ICUs, such as the ABCDEF, nutrition therapy, and ICU diary, for patients with coronavirus disease 2019 infection in ICUs and their association with ICU clinical practice and setting. Design: A worldwide, 2-day point prevalence study. Setting: The study was carried out on June 3, 2020, and July 1, 2020. A total of 212 ICUs in 38 countries participated. Clinicians in each participating ICU completed web-based online surveys. Patients: The ICU patients with coronavirus disease 2019. Interventions: None. Measurements and Main results: The implementation rate for the elements of the ABCDEF bundle, other supportive ICU care measures, and implementation-associated structures were investigated. Data were collected for 262 patients, of whom 47.3% underwent mechanical ventilation and 4.6% were treated with extracorporeal membrane oxygenation. Each element was implemented for the following percentages of patients: elements A (regular pain assessment), 45%; B (both spontaneous awakening and breathing trials), 28%; C (regular sedation assessment), 52%; D (regular delirium assessment), 35%; E (early mobility and exercise), 47%; and F (family engagement and empowerment), 16%. The implementation of element E was 4% for patients on mechanical ventilation and 8% for patients on extracorporeal membrane oxygenation. Supportive care, such as protein provision throughout the ICU stay (under 1.2 g/kg for more than 50% of the patients) and introduction of ICU diary (25%), was infrequent. Implementation rates of elements A and D were higher in ICUs with specific protocols and fewer ICU beds exclusively for patients with coronavirus disease 2019 infection. Element E was implemented at a higher rate in ICUs that had more ICU beds assigned for them. Conclusions: This point prevalence study showed low implementation of the ABCDEF bundle. Specific protocols and the number of ICU beds reserved for patients with coronavirus disease 2019 infection might be key factors for delivering appropriate supportive care.
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Mart MF, Williams Roberson S, Salas B, Pandharipande PP, Ely EW. Prevention and Management of Delirium in the Intensive Care Unit. Semin Respir Crit Care Med 2021; 42:112-126. [PMID: 32746469 PMCID: PMC7855536 DOI: 10.1055/s-0040-1710572] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.
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Affiliation(s)
- Matthew F. Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Bioengineering, Vanderbilt University, Nashville, Tennessee
| | - Barbara Salas
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee
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Liang S, Chau JPC, Lo SHS, Li S, Gao M. Implementation of ABCDEF care bundle in intensive care units: A cross-sectional survey. Nurs Crit Care 2021; 26:386-396. [PMID: 33522036 DOI: 10.1111/nicc.12597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Delirium affects up to 80% of patients in intensive care units (ICUs) and is associated with higher mortality, physical dependence, and health care costs. The 2018 pain, agitation, delirium, immobility, and sleep guideline recommended ABCDEF care bundle for delirium prevention and management. However, limited information is available regarding the adoption of the care bundle in ICUs in Mainland China. AIMS AND OBJECTIVES To assess the current implementation of the ABCDEF care bundle for delirium prevention as reported by ICU nurses in Mainland China. DESIGN A cross-sectional study was conducted. METHODS A cross-sectional online survey using a validated questionnaire about the practices of the ABCDEF care bundle was conducted among 334 registered nurses in 167 ICUs of 65 cities in Mainland China. RESULTS Almost 50% of the sampled ICU nurses were unaware of the ABCDEF care bundle, though 86.83% of the surveyed ICUs implemented pain assessments and 95.51% implemented sedation assessments. Nearly half (46.41%) of the surveyed ICUs performed routine spontaneous awaking trials, with 21.26% performing them daily. Spontaneous breathing trials were performed in 38.32% of the surveyed ICUs. Only 47% of the surveyed ICUs routinely monitored patients for delirium. About one-third (38.35%) of the surveyed ICUs were supported by specialist teams that implemented the mobilization programmes. Most ICUs restricted the duration of family visits per day (<0.5 hour: 61.67%; 0.5-2 hours: 23.65%; >2 hours: 3.29%) and only 28.14% of the surveyed ICUs employed dedicated staff to support the families. CONCLUSIONS Although most of the surveyed ICUs implemented pain and sedation assessments, many of them did not implement structured delirium assessments. Early mobilization programmes and family participation should be encouraged. RELEVANCE TO CLINICAL PRACTICE Promoting the uses of a reliable delirium assessment tool such as Confusion Assessment Method for Intensive Care Unit patients, building an early mobilization team, and engaging family caregivers in the care plan may contribute to improved patients' clinical outcomes.
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Affiliation(s)
- Surui Liang
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Janita Pak Chun Chau
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Suzanne Hoi Shan Lo
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Shunling Li
- The Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Mingrong Gao
- The Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Abstract
The psychological impact of critical illness is far reaching, affecting patients and their loved ones. Family members face a multitude of stressors, ranging from concerns about death or permanent disability to stress over health care costs and lost wages. Patients are at risk for developing post-intensive care syndrome. Professional groups and patient safety organizations have crafted family-centered care (FCC) models that support hospitalized patients and their families. There is a paucity of data on use of FCC in cardiothoracic intensive care units. This article discusses FCC models and why they are beneficial to the needs of families of postoperative cardiothoracic surgery patients.
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Roberson SW, Patel MB, Dabrowski W, Ely EW, Pakulski C, Kotfis K. Challenges of Delirium Management in Patients with Traumatic Brain Injury: From Pathophysiology to Clinical Practice. Curr Neuropharmacol 2021; 19:1519-1544. [PMID: 33463474 PMCID: PMC8762177 DOI: 10.2174/1570159x19666210119153839] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/12/2020] [Accepted: 01/13/2021] [Indexed: 11/22/2022] Open
Abstract
Traumatic brain injury (TBI) can initiate a very complex disease of the central nervous system (CNS), starting with the primary pathology of the inciting trauma and subsequent inflammatory and CNS tissue response. Delirium has long been regarded as an almost inevitable consequence of moderate to severe TBI, but more recently has been recognized as an organ dysfunction syndrome with potentially mitigating interventions. The diagnosis of delirium is independently associated with prolonged hospitalization, increased mortality and worse cognitive outcome across critically ill populations. Investigation of the unique problems and management challenges of TBI patients is needed to reduce the burden of delirium in this population. In this narrative review, possible etiologic mechanisms behind post-traumatic delirium are discussed, including primary injury to structures mediating arousal and attention and secondary injury due to progressive inflammatory destruction of the brain parenchyma. Other potential etiologic contributors include dysregulation of neurotransmission due to intravenous sedatives, seizures, organ failure, sleep cycle disruption or other delirium risk factors. Delirium screening can be accomplished in TBI patients and the presence of delirium portends worse outcomes. There is evidence that multi-component care bundles including an analgesia-prioritized sedation algorithm, regular spontaneous awakening and breathing trials, protocolized delirium assessment, early mobility and family engagement can reduce the burden of ICU delirium. The aim of this review is to summarize the approach to delirium in TBI patients with an emphasis on pathogenesis and management. Emerging CNS-active drug therapies that show promise in preclinical studies are highlighted.
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Affiliation(s)
| | | | | | | | | | - Katarzyna Kotfis
- Address correspondence to this author at the Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland; E-mail:
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Liang S, Chau JPC, Lo SHS, Bai L, Yao L, Choi KC. Validation of PREdiction of DELIRium in ICu patients (PRE-DELIRIC) among patients in intensive care units: A retrospective cohort study. Nurs Crit Care 2020; 26:176-182. [PMID: 32954624 DOI: 10.1111/nicc.12550] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/18/2020] [Accepted: 08/21/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND An intensive care unit (ICU) delirium prediction tool, PREdiction of DELIRium in ICu patients (PRE-DELIRIC), has been developed and calibrated in a multinational project. However, there is a lack of evidence regarding the predictive ability of the PRE-DELIRIC among Chinese ICU patients. AIM To evaluate the predictive validity (discrimination and calibration) of PRE-DELIRIC. DESIGN This is a retrospective cohort study. METHODS A retrospective cohort study was conducted. Consecutive participants (a) admitted to the ICU for ≥24 hours, (b) aged ≥18 years, and (c) admitted to the ICU for the first time were included. Ten predictors (age, APACHE-II, urgent and admission category, urea level, metabolic acidosis, infection, coma, sedation, and morphine use) assessed within 24 hours upon ICU admission were assessed. Delirium was assessed using the Confusion Assessment Method for ICU. Outcomes included ICU length of stay and mortality. Discrimination and calibration were determined by the areas under the receiver operating characteristic curve (AUROC), box plot, and calibration plot. RESULTS A total of 375 ICU patients were included, with 44.0% of patients being delirious. Delirium was significantly associated with age, PRE-DELIRIC score, ICU length of stay, and mortality. The AUROC was 0.81 (95% confidence interval, 0.77-0.86). The optimal cut-off point identified by max Youden index was 49%. The calibration plot of pooled data demonstrated a calibration slope of 0.894 and an intercept of -0.178. CONCLUSIONS The PRE-DELIRIC has high predictive value and is suggested to be adopted in ICUs for early initiation of preventive interventions against delirium among high-risk patients. RELEVANCE TO CLINICAL PRACTICE Clinicians can adopt the PRE-DELIRIC among ICU patients to screen patients at high risk of developing delirium. Early initiative interventions could be implemented to reduce the negative impacts of ICU delirium.
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Affiliation(s)
- Surui Liang
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Janita Pak Chun Chau
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Suzanne Hoi Shan Lo
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Liping Bai
- Surgical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Li Yao
- Nursing Department, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Kai Chow Choi
- The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
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Organizational Characteristics Associated With ICU Liberation (ABCDEF) Bundle Implementation by Adult ICUs in Michigan. Crit Care Explor 2020; 2:e0169. [PMID: 32885171 DOI: 10.1097/cce.0000000000000169] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The ICU Liberation (ABCDEF) Bundle can help to improve care and outcomes for ICU patients, but bundle implementation is far from universal. Understanding how ICU organizational characteristics influence bundle implementation could inform quality improvement efforts. We surveyed all hospitals in Michigan with adult ICUs to determine whether organizational characteristics were associated with bundle implementation and to determine the level of agreement between ICU physician and nurse leaders around ICU organizational characteristics and bundle implementation. Design We surveyed ICU physician and nurse leaders, assessing their safety culture, ICU team collaboration, and work environment. Using logistic and linear regression models, we compared these organizational characteristics to bundle element implementation, and also compared physician and nurse leaders' perceptions about organizational characteristics and bundle implementation. Setting All (n = 72) acute care hospitals with adult ICUs in Michigan. Subjects ICU physician and nurse leader pairs from each hospital's main ICU. Interventions We developed, pilot-tested, and deployed an electronic survey to all subjects over a 3 month period in 2016. Results Results from 73 surveys (28 physicians, 45 nurses, 60% hospital response rate) demonstrated significant variation in hospital and ICU size and type, organizational characteristics, and physician/nurse perceptions of ICU organization and bundle implementation. We found that a robust safety culture and collaborative work environment that uses checklists to facilitate team communication are strongly associated with bundle implementation. There is also a significant dose-response effect between safety culture, a collaborative work environment, and overall bundle implementation. Conclusions We identified several specific ICU practices that can facilitate ABCDEF Bundle implementation. Our results can be used to develop effective bundle implementation strategies that leverage safety culture, interprofessional collaboration, and routine checklist use in ICUs to improve bundle implementation and performance.
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Gosselin É, Richard-Lalonde M. Role of Family Members in Pain Management in Adult Critical Care. AACN Adv Crit Care 2020; 30:398-410. [PMID: 31951660 DOI: 10.4037/aacnacc2019275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
This review describes family member involvement in intensive care unit pain assessment and management and generates implications for clinical practice, education, and future research. A literature review was performed in MEDLINE, PubMed, EMBASE, Cochrane, and CINAHL databases from their inception until April 30, 2019. Only 11 studies addressing the topic were identified, and the current quality of evidence is low. Family members can be involved in pain assessment by describing patients' pain behaviors and in pain management by selecting and delivering nonpharmacological interventions tailored to patients' needs, if the family members feel comfortable with this role. More-rigorous research is required to describe the role of family members in patients' pain assessment and management. Advancing knowledge in this field could improve patients' and family members' experiences with pain assessment and management in the intensive care unit.
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Affiliation(s)
- Émilie Gosselin
- Émilie Gosselin is a Postdoctoral Research Fellow, Ingram School of Nursing, McGill University, and Center for Nursing Research, Jewish General Hospital of Montreal, 680 Sherbrooke St West, Room 1838, Montreal, QC H3A 2M7, Canada . Mélissa Richard-Lalonde is a Doctoral Student, Ingram School of Nursing, McGill University
| | - Mélissa Richard-Lalonde
- Émilie Gosselin is a Postdoctoral Research Fellow, Ingram School of Nursing, McGill University, and Center for Nursing Research, Jewish General Hospital of Montreal, 680 Sherbrooke St West, Room 1838, Montreal, QC H3A 2M7, Canada . Mélissa Richard-Lalonde is a Doctoral Student, Ingram School of Nursing, McGill University
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Strategies to Optimize ICU Liberation (A to F) Bundle Performance in Critically Ill Adults With Coronavirus Disease 2019. Crit Care Explor 2020; 2:e0139. [PMID: 32696002 PMCID: PMC7314345 DOI: 10.1097/cce.0000000000000139] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Supplemental Digital Content is available in the text. Objectives: The severe acute respiratory syndrome coronavirus 2 pandemic has stretched ICU resources in an unprecedented fashion and outstripped personal protective equipment supplies. The combination of a novel disease, resource limitations, and risks to medical personnel health have created new barriers to implementing the ICU Liberation (“A” for Assessment, Prevention, and Manage pain; “B” for Both Spontaneous Awakening Trials and Spontaneous Breathing Trials; “C” for Choice of Analgesia and Sedation; “D” for Delirium Assess, Prevent, and Manage; “E” for Early Mobility and Exercise; and “F” for Family Engagement and Empowerment [ABCDEF]) Bundle, a proven ICU care approach that reduces delirium, shortens mechanical ventilation duration, prevents post-ICU syndrome, and reduces healthcare costs. This narrative review acknowledges barriers and offers strategies to optimize Bundle performance in coronavirus disease 2019 patients requiring mechanical ventilation. Data Sources, Study Selection, and Data Extraction: The most relevant literature, media reports, and author experiences were assessed for inclusion in this narrative review including PubMed, national newspapers, and critical care/pharmacology textbooks. Data Synthesis: Uncertainty regarding coronavirus disease 2019 clinical course, shifts in attitude, and changes in routine behavior have hindered Bundle use. A domino effect results from: 1) changes to critical care hierarchy, priorities, and ICU team composition; 2) significant personal protective equipment shortages cause; 3) reduced/restricted physical bedside presence favoring; 4) increased depth of sedation and use of neuromuscular blockade; 5) which exacerbate drug shortages; and 6) which require prolonged use of limited ventilator resources. Other identified barriers include manageable knowledge deficits among non-ICU clinicians unfamiliar with the Bundle or among PICU specialists deploying pediatric-based Bundle approaches who are unfamiliar with adult medicine. Both groups have been enlisted to augment the adult ICU work force to meet demand. Strategies were identified to facilitate Bundle performance to liberate patients from the ICU. Conclusions: We acknowledge current challenges that interfere with comprehensive management of critically ill patients during the coronavirus disease 2019 pandemic. Rapid response to new circumstances precisely requires established safety mechanisms and protocols like the ABCDEF Bundle to increase ICU and ventilator capacity and help survivors maximize recovery from coronavirus disease 2019 as early as possible.
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Abstract
Purpose of Review We briefly review post-intensive care syndrome (PICS) and the morbidities associated with critical illness that led to the intensive care unit (ICU) liberation movement. We review each element of the ICU liberation bundle, including pediatric support data, as well as tips and strategies for implementation in a pediatric ICU (PICU) setting. Recent Findings Numerous studies have found children have cognitive, physical, and psychiatric deficits after a PICU stay. The effects of the full ICU liberation bundle in children have not been published, but in adults, bundle implementation (even partial) resulted in significant improvement in survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition. Summary Although initially described in adults, children also suffer from PICS. The ICU liberation bundle is feasible in children and may ameliorate the effects of a PICU stay. Further studies are needed to characterize the benefits of the ICU liberation bundle in children.
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Affiliation(s)
- Alice Walz
- 1Department of Pediatrics, Medical University of South Carolina, Charleston, SC USA
| | - Marguerite Orsi Canter
- Department of Pediatrics, NYU Winthrop Hospital, Long Island School of Medicine, Mineola, NY USA
| | - Kristina Betters
- 3Department of Pediatrics, Vanderbilt University School of Medicine, Doctors Office Tower 5114, 2200 Children's Way, Nashville, TN 37232 USA
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Ervin JN. An acceptability pilot of the facilitating active management in lung illness with engaged surrogates (FAMILIES) study. Medicine (Baltimore) 2020; 99:e19272. [PMID: 32118736 PMCID: PMC7478694 DOI: 10.1097/md.0000000000019272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 01/10/2020] [Accepted: 01/22/2020] [Indexed: 11/26/2022] Open
Abstract
Approximately half of the surrogate decision makers of critically ill adults are at risk for negative emotional burden. Decision support and effective surrogate-clinician communication buffers against such experiences. The objective of this study is to evaluate the acceptability of a new surrogate-targeted educational tool that promotes engagement with clinicians and advocacy for 2 evidence-based practices in the provision of mechanical ventilation for acute respiratory failure: spontaneous awakening and breathing trials.A panel of 44 former patients and surrogates of a 20-bed medical intensive care unit in a large academic hospital responded to an online survey. Acceptability was measured on 3 dimensions: attitudes toward the content and delivery of information, objective knowledge translation, and subjective knowledge acquisition.More than 80% of participants found the tool to be easy to read, and over 90% felt that the tool provided actionable recommendations. A significant number of previously unsure participants were able to identify what spontaneous awakening and breathing trials are and when they occur, and 16% to 36% reported significant improvements in their subjective understanding of the target evidence-based practices, after being exposed to the educational tool.This line of work seeks to reduce surrogates' negative emotional burden while also promoting quality critical care. The educational tool provides a promising new way to promote surrogate-clinician communication, by increasing surrogates' knowledge about and encouraging advocacy for evidence-based practices in the provision of mechanical ventilation.
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Kotfis K, Roberson SW, Wilson JE, Pun BT, Ely EW, Jeżowska I, Jezierska M, Dabrowski W. COVID-19: What do we need to know about ICU delirium during the SARS-CoV-2 pandemic? Anaesthesiol Intensive Ther 2020; 52:132-138. [PMID: 32419438 PMCID: PMC7667988 DOI: 10.5114/ait.2020.95164] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 01/15/2023] Open
Abstract
In March 2020, the World Health Organisation announced the COVID-19 pandemic caused by the SARS-CoV-2 virus. As well as respiratory failure, the SARS-CoV-2 may cause central nervous system (CNS) involvement, including delirium occurring in critically ill patients (ICU delirium). Due attention must be paid to this subject in the face of the COVID-19 pandemic. Delirium, the detection of which takes less than two minutes, is frequently underestimated during daily routine ICU care, but it may be a prodromal symptom of infection or hypoxia associated with severe respiratory failure. During the COVID-19 pandemic, systematic delirium monitoring using validated tests (CAM-ICU or ICDSC) may be sacrificed. This is likely to be due to the fact that the main emphasis is placed on organisational issues, i.e. the lack of ventilators, setting priorities for limited mechanical ventilation options, and a shortage of personal protective equipment. Early identification of patients with delirium is critical in patients with COVID-19 because the occurrence of delirium may be an early symptom of worsening respiratory failure or of infectious spread to the CNS mediated by potential neuroinvasive mechanisms of the coronavirus. The purpose of this review is to identify problems related to the development of delirium during the COVID-19 epidemic, which are presented in three areas: i) factors contributing to delirium in COVID-19, ii) potential pathophysiological factors of delirium in COVID-19, and iii) long-term consequences of delirium in COVID-19. This article discusses how healthcare workers can reduce the burden of delirium by identifying potential risk factors and difficulties during challenges associated with SARS-CoV-2 infection.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anaesthesiology, Intensive Therapy, and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Bioengineering, Vanderbilt University, Nashville, TN, United States
| | - Jo Ellen Wilson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
- Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Healthcare System, Nashville, TN, United States
| | - Brenda T. Pun
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, United States
- Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Veterans Affairs Healthcare System, Nashville, TN, United States
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ilona Jeżowska
- Integrative Counselling and Psychotherapy, The Minster Centre, Department of Psychology, Middlesex University, London, UK
| | - Maja Jezierska
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Poland
| | - Wojciech Dabrowski
- Department of Anaesthesiology and Intensive Care, Medical University of Lublin, Poland
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Thompson-Brazill KA. Pain Control in the Cardiothoracic Surgery Patient. Crit Care Nurs Clin North Am 2019; 31:389-405. [DOI: 10.1016/j.cnc.2019.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Balas MC, Barnes-Daly MA, Byrum DG, Posa PJ, Pun BT, Puntillo KA. The Authors Respond. Crit Care Nurse 2019; 39:14-15. [PMID: 31154325 DOI: 10.4037/ccn2019690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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