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Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA. Pain, Anxiety, and the Continuous Use of Opioids and Benzodiazepines in Trauma Intensive Care Unit Survivors: An Exploratory Study. P R Health Sci J 2022; 41:111-116. [PMID: 36018737 PMCID: PMC9469201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To evaluate at-home opioid and benzodiazepine use, the degrees of pain and anxiety, and the incidence of probable withdrawal in post-discharge Trauma Intensive Care Unit (TICU) survivors. METHODS This was an exploratory study of post-TICU survivors who had participated in a previous study of opioid and benzodiazepine withdrawal. We surveyed survivors by telephone asking for retrospective information (during their first 4-months postdischarge- Time 1) and current information (around 2-years post-discharge- Time 2). RESULTS A mostly male (82%), young (median 38 years [IQR, 28-52]) sample of 27 TICU survivors reported using opioids (56%) at Time 1 for a median of 30 (IQR,14-90) days. Twelve percent of 26 survivors were still using opioids at Time 2. Sixty percent of the survivors had pain during Time 1, a median pain score of 6 (IQR, 5-8) on a 0-10 numeric rating scale (NRS).; 57% had pain at Time 2, median NRS score=6 (IQR, 4-7). Sixty-five percent of survivors had anxiety during Time 1, NRS median=7 (IQR, 5-9); 50% had anxiety at Time 2, NRS median= 6 (IQR, 3-7). At Time 1, 26% used prescribed benzodiazepines, and 12% used benzodiazepines at Time 2. Five and one of the 27 patients reported symptoms of opioid or benzodiazepine withdrawal, respectively, upon discontinuation or weaning. CONCLUSION Many TICU survivors had discontinued opioid/benzodiazepine prescriptions by 4-months post discharge while half reporting pain/anxiety for up to 2-years. Investigating the effects of acute-to-chronic pain in ICU survivors and gaining a better understanding of the mechanisms of prolonged opioid use are warranted.
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Affiliation(s)
- Carmen Mabel Arroyo-Novoa
- Professor, School of Nursing, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Milagros I Figueroa-Ramos
- Professor, School of Nursing, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
| | - Kathleen A Puntillo
- Professor Emeritus, School of Nursing, University of California, San Francisco, California, USA
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Erikson AE, Puntillo KA, McAdam JL. Bereavement Experiences of Families in the Cardiac Intensive Care Unit. Am J Crit Care 2022; 31:13-23. [PMID: 34972855 DOI: 10.4037/ajcc2022859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Losing a loved one in the intensive care unit is associated with complicated grief and increased psychologic distress for families. Providing bereavement support may help families during this time. However, little is known about the bereavement experiences of families of patients in the cardiac intensive care unit. OBJECTIVE To describe the bereavement experiences of families of patients in the cardiac intensive care unit. METHODS In this secondary analysis, an exploratory, descriptive design was used to understand the families' bereavement experiences. Families from 1 cardiac intensive care unit in a tertiary medical center in the western United States participated. Audiotaped telephone interviews were conducted by using a semistructured interview guide 13 to 15 months after the patient's death. A qualitative, descriptive technique was used for data analysis. Two independent researchers coded the interview transcripts and identified themes. RESULTS Twelve family members were interviewed. The majority were female (n = 8, 67%), spouses (n = 10, 83%), and White (n = 10, 83%); the mean age (SD) was 58.4 (16.7) years. Five main themes emerged: (1) families' bereavement work included both practical tasks and emotional processing; (2) families' bereavement experiences were individual; (3) these families were resilient and found their own resources and coping mechanisms; (4) the suddenness of a patient's death influenced families' bereavement experiences; and (5) families' experiences in the intensive care unit affected their bereavement. CONCLUSIONS This study provided insight into the bereavement experiences of families of patients in the cardiac intensive care unit. These findings may be useful for professionals working with bereaved families and for cardiac intensive care units considering adding bereavement support.
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Affiliation(s)
- Alyssa E. Erikson
- Alyssa E. Erikson is an associate professor, California State University, Monterey Bay, California
| | - Kathleen A. Puntillo
- Kathleen A. Puntillo is a professor emeritus, University of California, San Francisco, California
| | - Jennifer L. McAdam
- Jennifer L. McAdam is a professor, Samuel Merritt University, San Mateo, California
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3
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Gélinas C, Bérubé M, Puntillo KA, Boitor M, Richard-Lalonde M, Bernard F, Williams V, Joffe AM, Steiner C, Marsh R, Rose L, Dale CM, Tsoller DM, Choinière M, Streiner DL. Validation of the Critical-Care Pain Observation Tool-Neuro in brain-injured adults in the intensive care unit: a prospective cohort study. Crit Care 2021; 25:142. [PMID: 33849619 PMCID: PMC8042624 DOI: 10.1186/s13054-021-03561-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/31/2021] [Indexed: 11/10/2022]
Abstract
Background Pain assessment in brain-injured patients in the intensive care unit (ICU) is challenging and existing scales may not be representative of behavioral reactions expressed by this specific group. This study aimed to validate the French-Canadian and English revised versions of the Critical-Care Pain Observation Tool (CPOT-Neuro) for brain-injured ICU patients. Methods A prospective cohort study was conducted in three Canadian and one American sites. Patients with a traumatic or a non-traumatic brain injury were assessed with the CPOT-Neuro by trained raters (i.e., research staff and ICU nurses) before, during, and after nociceptive procedures (i.e., turning and other) and non-nociceptive procedures (i.e., non-invasive blood pressure, soft touch). Patients who were conscious and delirium-free were asked to provide their self-report of pain intensity (0–10). A first data set was completed for all participants (n = 226), and a second data set (n = 87) was obtained when a change in the level of consciousness (LOC) was observed after study enrollment. Three LOC groups were included: (a) unconscious (Glasgow Coma Scale or GCS 4–8); (b) altered LOC (GCS 9–12); and (c) conscious (GCS 13–15). Results Higher CPOT-Neuro scores were found during nociceptive procedures compared to rest and non-nociceptive procedures in both data sets (p < 0.001). CPOT-Neuro scores were not different across LOC groups. Moderate correlations between CPOT-Neuro and self-reported pain intensity scores were found at rest and during nociceptive procedures (Spearman rho > 0.40 and > 0.60, respectively). CPOT-Neuro cut-off scores ≥ 2 and ≥ 3 were found to adequately classify mild to severe self-reported pain ≥ 1 and moderate to severe self-reported pain ≥ 5, respectively. Interrater reliability of raters’ CPOT-Neuro scores was supported with intraclass correlation coefficients > 0.69. Conclusions The CPOT-Neuro was found to be valid in this multi-site sample of brain-injured ICU patients at various LOC. Implementation studies are necessary to evaluate the tool’s performance in clinical practice. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03561-1.
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Affiliation(s)
- Céline Gélinas
- Ingram School of Nursing, McGill University, 680 Sherbrooke West St., Suite 1800, Montreal, QC, H3A 2M7, Canada. .,Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, CIUSSS West-Central Montreal, 3755 Côte-Sainte-Catherine Road, Montreal, QC, H3T 1E2, Canada.
| | - Mélanie Bérubé
- Faculty of Nursing, Université Laval, 1050 Avenue de la Médecine, Room 3486, Quebec City, QC, G1V 0A6, Canada.,Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval, 1401, 18e rue, Room Z-243, Quebec City, QC, G1J 1Z4, Canada
| | - Kathleen A Puntillo
- Physiological Nursing, University of California San Francisco, 2 Koret Way, San Francisco, CA, 94143, USA
| | - Madalina Boitor
- Faculty of Dentistry, McGill University, 3640 University St., Montreal, QC, H3A 0C7, Canada
| | - Melissa Richard-Lalonde
- Ingram School of Nursing, McGill University, 680 Sherbrooke West St., Suite 1800, Montreal, QC, H3A 2M7, Canada.,Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, CIUSSS West-Central Montreal, 3755 Côte-Sainte-Catherine Road, Montreal, QC, H3T 1E2, Canada
| | - Francis Bernard
- Équipe de Recherche en Soins Intensifs (ERESI), Research centre, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur-de-Montréal, 5400 boulevard Gouin Ouest, K-3000, Montreal, QC, H4J 1C4, Canada.,Department of Medicine, Université de Montréal, Succursale Centre-Ville, C.P. 6128, Montreal, QC, H3C 3J7, Canada
| | - Virginie Williams
- Équipe de Recherche en Soins Intensifs (ERESI), Research centre, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Coeur-de-Montréal, 5400 boulevard Gouin Ouest, K-3000, Montreal, QC, H4J 1C4, Canada
| | - Aaron M Joffe
- School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.,Harborview Medical Center, University of Washington Medicine, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Craig Steiner
- School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA
| | - Rebekah Marsh
- Harborview Medical Center, University of Washington Medicine, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Rd, London, SE1 8WA, UK.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada
| | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.,Tory Trauma Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, M4N 3M5, Canada
| | - Darina M Tsoller
- Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, CIUSSS West-Central Montreal, 3755 Côte-Sainte-Catherine Road, Montreal, QC, H3T 1E2, Canada
| | - Manon Choinière
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Succursale Centre-Ville, C.P. 6128, Montreal, QC, H3C 3J7, Canada.,Research Center, Centre Hospitalier de l'Université de Montréal, Saint Antoine Building, Room S01-126, 850 Saint Denis St, Montreal, QC, H2X 0A9, Canada
| | - David L Streiner
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare, 100 West 5th Street, Box 585, Hamilton, ON, L8N 3K7, Canada
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Gélinas C, Joffe AM, Szumita PM, Payen JF, Bérubé M, Shahiri T S, Boitor M, Chanques G, Puntillo KA. A Psychometric Analysis Update of Behavioral Pain Assessment Tools for Noncommunicative, Critically Ill Adults. AACN Adv Crit Care 2020; 30:365-387. [PMID: 31951666 DOI: 10.4037/aacnacc2019952] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
This is an updated, comprehensive review of the psychometric properties of behavioral pain assessment tools for use with noncommunicative, critically ill adults. Articles were searched in 5 health databases. A total of 106 articles were analyzed, including 54 recently published papers. Nine behavioral pain assessment tools developed for noncommunicative critically ill adults and 4 tools developed for other non-communicative populations were included. The scale development process, reliability, validity, feasibility, and clinical utility were analyzed using a 0 to 20 scoring system, and quality of evidence was also evaluated. The Behavioral Pain Scale, the Behavioral Pain Scale-Nonintubated, and the Critical-Care Pain Observation Tool remain the tools with the strongest psychometric properties, with validation testing having been conducted in multiple countries and various languages. Other tools may be good alternatives, but additional research on them is necessary.
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Affiliation(s)
- Céline Gélinas
- Céline Gélinas is Associate Professor, Ingram School of Nursing, McGill University, 680 Sherbrooke West, Room 1838, Montréal, Québec, Canada, H3A 2M7; and Researcher, Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, Montréal, Québec, Canada
| | - Aaron M Joffe
- Aaron M. Joffe is Professor, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Paul M Szumita
- Paul M. Szumita is Clinical Pharmacy Practice Manager and Program Director - PGY2 Critical Care Pharmacy Practice Residency, Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jean-Francois Payen
- Jean-Francois Payen is Professor, Department of Anesthesiology and Critical Care, and Researcher, Inserm, U1216, Grenoble Institut Neurosciences, Grenoble Alpes University Hospital, Grenoble, France
| | - Mélanie Bérubé
- Mélanie Bérubé is Assistant Professor, Faculty of Nursing, Université Laval; and Researcher, CHU de Québec, Université Laval Research Center (Hôpital de l'Enfant-Jésus), Québec City, Québec, Canada
| | - Shiva Shahiri T
- Shiva Shahiri T is a PhD Student, Ingram School of Nursing, McGill University
| | - Madalina Boitor
- Madalina Boitor is a Student, Faculty of Dentistry, McGill University
| | - Gerald Chanques
- Gerald Chanques is Professor, Department of Anesthesia & Critical Care Medicine, Montpellier University Hospital Saint Eloi, and PhyMedExp, University of Montpellier, INSERM, CNRS, 34295 Montpellier cedex 5, France
| | - Kathleen A Puntillo
- Kathleen A. Puntillo is Professor of Nursing Emeritus, University of California San Francisco School of Nursing, San Francisco, California
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5
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Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA, Gélinas C. Translation into Spanish and Cultural Adaptation of the Critical-Care Pain Observation Tool. Am J Crit Care 2020; 29:226-232. [PMID: 32355973 DOI: 10.4037/ajcc2020763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The Critical-Care Pain Observation Tool (CPOT) is recommended for evaluating pain behaviors in patients in the intensive care unit who are unable to report pain. The source of the only published Spanish version of the CPOT does not verify that it underwent a formal translation process. OBJECTIVE To describe the translation into Spanish and cultural adaptation of the original French version of the CPOT. METHODS Key persons in the translation process included one with a master's degree in translation, a critical care physician, nurse faculty members with vast experience in intensive care units, and the instrument's developer. This team followed the Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes Measures as a guide to translate and culturally adapt the CPOT. RESULTS The first Spanish-language version was back translated to French and was also compared with the English version. Revisions necessitated a second version, which was submitted to experts in critical care. Their modifications required a third version, which was back translated to French and discussed with the CPOT developer, after which a fourth version was created. Finally, a linguistic expert proofread the tool, and the translation leaders incorporated the recommendations, thereby obtaining a final Spanish version. CONCLUSION The Spanish version is ready to undergo validation with patients in the intensive care unit, which is the next step toward its use in assessing pain behaviors among patients in intensive care units where Spanish is spoken.
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Affiliation(s)
- Carmen Mabel Arroyo-Novoa
- Carmen Mabel Arroyo-Novoa and Milagros I. Figueroa-Ramos are professors at the University of Puerto Rico, Medical Sciences Campus, School of Nursing, San Juan, Puerto Rico
| | - Milagros I. Figueroa-Ramos
- Carmen Mabel Arroyo-Novoa and Milagros I. Figueroa-Ramos are professors at the University of Puerto Rico, Medical Sciences Campus, School of Nursing, San Juan, Puerto Rico
| | - Kathleen A. Puntillo
- Kathleen A. Puntillo is a professor emeritus at the University of California, San Francisco, School of Nursing, San Francisco, California
| | - Céline Gélinas
- Céline Gélinas is an associate professor in the Faculty of Medicine, Ingram School of Nursing, McGill University, and a nurse researcher at the Centre for Nursing Research and Lady Davis Institute, CIUSSS West-Central-Montreal, Jewish General Hospital, Montreal, Canada
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Abstract
Iatrogenic withdrawal syndrome is an increasingly recognized issue among adult patients in the intensive care unit. The prolonged use of opioids and benzodiazepines during the intensive care unit stay and preexisting disorders associated with their use put patients at risk of developing iatrogenic withdrawal syndrome. Although research to date is scant regarding iatrogenic withdrawal syndrome in adult patients in the intensive care unit, it is important to recognize and adequately manage iatrogenic withdrawal syndrome in order to prevent possible negative outcomes during and after a patient's intensive care unit stay. This article discusses in depth 8 studies of iatrogenic withdrawal syndrome among adult patients in the intensive care unit. It also addresses important aspects of opioid and benzodiazepine iatrogenic withdrawal syndrome, including prevalence, risk factors, and assessment and considers its prevention and management.
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Affiliation(s)
- Carmen Mabel Arroyo-Novoa
- Carmen Mabel Arroyo-Novoa is Associate Professor, Graduate Department, University of Puerto Rico School of Nursing, Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067 . Milagros I. Figueroa-Ramos is Associate Professor, Graduate Department, University of Puerto Rico School of Nursing, San Juan, Puerto Rico. Kathleen A. Puntillo is Professor Emeritus, Physiological Nursing Department, University of California, San Francisco, School of Nursing, San Francisco, California
| | - Milagros I Figueroa-Ramos
- Carmen Mabel Arroyo-Novoa is Associate Professor, Graduate Department, University of Puerto Rico School of Nursing, Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067 . Milagros I. Figueroa-Ramos is Associate Professor, Graduate Department, University of Puerto Rico School of Nursing, San Juan, Puerto Rico. Kathleen A. Puntillo is Professor Emeritus, Physiological Nursing Department, University of California, San Francisco, School of Nursing, San Francisco, California
| | - Kathleen A Puntillo
- Carmen Mabel Arroyo-Novoa is Associate Professor, Graduate Department, University of Puerto Rico School of Nursing, Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067 . Milagros I. Figueroa-Ramos is Associate Professor, Graduate Department, University of Puerto Rico School of Nursing, San Juan, Puerto Rico. Kathleen A. Puntillo is Professor Emeritus, Physiological Nursing Department, University of California, San Francisco, School of Nursing, San Francisco, California
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7
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Stollings JL, Devlin JW, Pun BT, Puntillo KA, Kelly T, Hargett KD, Morse A, Esbrook CL, Engel HJ, Perme C, Barnes-Daly MA, Posa PJ, Aldrich JM, Barr J, Carson SS, Schweickert WD, Byrum DG, Harmon L, Ely EW, Balas MC. Implementing the ABCDEF Bundle: Top 8 Questions Asked During the ICU Liberation ABCDEF Bundle Improvement Collaborative. Crit Care Nurse 2019; 39:36-45. [PMID: 30710035 DOI: 10.4037/ccn2019981] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment) improves intensive care unit patient-centered outcomes and promotes interprofessional teamwork and collaboration. The Society of Critical Care Medicine recently completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, multicenter, national quality improvement initiative that formalized dissemination and implementation strategies to promote effective adoption of the ABCDEF bundle. The purpose of this article is to describe 8 of the most frequently asked questions during the Collaborative and to provide practical advice from leading experts to other institutions implementing the ABCDEF bundle.
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Affiliation(s)
- Joanna L Stollings
- Joanna Stollings is a clinical pharmacist, Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - John W Devlin
- John Devlin is Professor of Pharmacy, Northeastern University, and a clinical scientist, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Brenda T Pun
- Joanna Stollings is a clinical pharmacist, Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kathleen A Puntillo
- Kathleen Puntillo is a professor of nursing emeritus, Department of Physiological Nursing, School of Nursing, University of California, San Francisco
| | - Tamra Kelly
- Tamra Kelly is a respiratory therapist, Sutter Health, Sacramento, California
| | - Ken D Hargett
- Ken Hargett is a respiratory therapist, Houston Methodist Hospital, Houston, Texas
| | | | - Cheryl L Esbrook
- Cheryl Esbrook is an occupational therapist, University of Chicago Medicine, Chicago, Illinois
| | - Heidi J Engel
- Heidi Engel is a physical therapist, Department of Rehabilitative Services, University of California, San Francisco
| | - Christiane Perme
- Christiane Perme is a physical therapist, Houston Methodist Hospital
| | - Mary Ann Barnes-Daly
- Mary Ann Barnes-Daly is a clinical performance improvement consultant, Sutter Health
| | - Patricia J Posa
- Patricia Posa is a population health clinical integration leader, Saint Joseph Mercy Health System, Ann Arbor, Michigan
| | - J Matthew Aldrich
- J. Matthew Aldrich is the Medical Director of Critical Care Medicine and an associate clinical professor, University of San Francisco, San Francisco
| | - Juliana Barr
- Juliana Barr is a staff intensivist and anesthesiologist, VA Palo Alto Health Care System, Palo Alto, California, and an associate professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Shannon S Carson
- Shannon Carson is a critical care pulmonologist, University of North Carolina School of Medicine, Chapel Hill
| | - William D Schweickert
- William Schweickert is an associate professor of clinical medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Diane G Byrum
- Diane Byrum is a quality implementation consultant, Innovative Solutions for Healthcare Education, LLC, Charlotte, North Carolina
| | - Lori Harmon
- Lori Harmon is director of quality, Society of Critical Care Medicine, Mount Prospect, Illinois
| | - E Wesley Ely
- E. Wesley Ely is a professor of medicine, Vanderbilt University School of Medicine, and associate director, VA Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - Michele C Balas
- Michele Balas is an associate professor, Center of Excellence in Critical and Complex Care, College of Nursing, and a nurse scientist, Wexner Medical Center, The Ohio State University, Columbus
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Balas MC, Pun BT, Pasero C, Engel HJ, Perme C, Esbrook CL, Kelly T, Hargett KD, Posa PJ, Barr J, Devlin JW, Morse A, Barnes-Daly MA, Puntillo KA, Aldrich JM, Schweickert WD, Harmon L, Byrum DG, Carson SS, Ely EW, Stollings JL. Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience. Crit Care Nurse 2019; 39:46-60. [PMID: 30710036 DOI: 10.4037/ccn2019927] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Although growing evidence supports the safety and effectiveness of the ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment), intensive care unit providers often struggle with how to reliably and consistently incorporate this interprofessional, evidence-based intervention into everyday clinical practice. Recently, the Society of Critical Care Medicine completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, nationwide, multicenter quality improvement initiative that formalized dissemination and implementation strategies and tracked key performance metrics to overcome barriers to ABCDEF bundle adoption. The purpose of this article is to discuss some of the most challenging implementation issues that Collaborative teams experienced, and to provide some practical advice from leading experts on ways to overcome these barriers.
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Affiliation(s)
- Michele C Balas
- Michele Balas is an associate professor, Center of Excellence in Critical and Complex Care, College of Nursing, and a nurse scientist, Wexner Medical Center, The Ohio State University, Columbus.
| | - Brenda T Pun
- Michele Balas is an associate professor, Center of Excellence in Critical and Complex Care, College of Nursing, and a nurse scientist, Wexner Medical Center, The Ohio State University, Columbus
| | - Chris Pasero
- Chris Pasero is a pain management clinical consultant, El Dorado Hills, California
| | - Heidi J Engel
- Heidi Engel is a physical therapist, Department of Rehabilitative Services, University of California, San Francisco
| | - Christiane Perme
- Christiane Perme is a physical therapist, Houston Methodist Hospital, Houston, Texas
| | - Cheryl L Esbrook
- Cheryl Esbrook is an occupational therapist, University of Chicago Medicine, Chicago, Illinois
| | - Tamra Kelly
- Tamra Kelly is a respiratory therapist, Sutter Health, Sacramento, California
| | - Ken D Hargett
- Ken Hargett is a respiratory therapist, Houston Methodist Hospital
| | - Patricia J Posa
- Patricia Posa is a population health clinical integration leader, Saint Joseph Mercy Health System, Ann Arbor, Michigan
| | - Juliana Barr
- Juliana Barr is a staff intensivist and anesthesiologist, VA Palo Alto Health Care System, Palo Alto, California, and an associate professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - John W Devlin
- John Devlin is a professor of pharmacy, Northeastern University, and a clinical scientist, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
| | | | - Mary Ann Barnes-Daly
- Mary Ann Barnes-Daly is a clinical performance improvement consultant, Sutter Health
| | - Kathleen A Puntillo
- Kathleen Puntillo is a professor of nursing emeritus, Department of Physiological Nursing, School of Nursing, University of California, San Francisco
| | - J Matthew Aldrich
- J. Matthew Aldrich is medical director, critical care medicine, and an associate clinical professor, University of California, San Francisco Medical Center, San Francisco
| | - William D Schweickert
- William Schweickert is an associate professor of clinical medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lori Harmon
- Lori Harmon is director of quality, Society of Critical Care Medicine, Mount Prospect, Illinois
| | - Diane G Byrum
- Diane Byrum is a quality implementation consultant, Innovative Solutions for Healthcare Education, LLC, Charlotte, North Carolina
| | - Shannon S Carson
- Shannon Carson is a critical care pulmonologist, University of North Carolina School of Medicine, Chapel Hill
| | - E Wesley Ely
- E. Wesley Ely is a professor of medicine, Vanderbilt University School of Medicine, and associate director, VA Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - Joanna L Stollings
- Joanna Stollings is a clinical pharmacist, Department of Pharmaceutical Services, Vanderbilt University Medical Center
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Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA. Occurrence and Practices for Pain, Agitation, and Delirium in Intensive Care Unit Patients. P R Health Sci J 2019; 38:156-162. [PMID: 31536628 PMCID: PMC6906604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Our study described the occurrence, assessment, prevention, and management practices of pain, agitation, and delirium (PAD) in four intensive care units (ICUs) from the Puerto Rico Medical Center and compared findings with the 2013 PAD guidelines. METHODS A descriptive study, with repeated bedside measures (two times a day/two times a week) of PAD and review of patient clinical records. RESULTS Eighty ICU patients (20 per ICU) were evaluated, (median 3 times [IQR, 2-7]). At least once during the assessment period, 57% percent of patients had significant pain and 34% had delirium. Moreover, 46% were deeply sedated, 17.5% had agitation, and 52.5% of patients were within the recommended Richmond Agitation-Sedation Scale (RASS) scores. The Numeric Rating Scale and RASS were the most common tools used by clinicians to evaluate pain and agitation/sedation levels, respectively. Clinicians did not assess pain in patients unable to self-report with any guideline-recommended tools, as was the case for delirium. Fentanyl and morphine were the most commonly used analgesics, while benzodiazepines were used for sedation. CONCLUSION Although pain, agitation, and delirium occurrence were similar to other studies, patients continue to suffer. A gap exists between clinical practices in these ICUs and current guidelines. Strategies that contribute to integrating guidelines into these ICUs should be developed, studied, and implemented.
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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] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Gélinas C, Boitor M, Puntillo KA, Arbour C, Topolovec-Vranic J, Cusimano MD, Choinière M, Streiner DL. Behaviors Indicative of Pain in Brain-Injured Adult Patients With Different Levels of Consciousness in the Intensive Care Unit. J Pain Symptom Manage 2019; 57:761-773. [PMID: 30593909 DOI: 10.1016/j.jpainsymman.2018.12.333] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/18/2018] [Accepted: 12/18/2018] [Indexed: 11/25/2022]
Abstract
CONTEXT Many brain-injured patients are unable to self-report their pain during their hospitalization in the intensive care unit (ICU), and existing behavioral pain scales may not be well suited. OBJECTIVES The objectives of this study were to describe and compare behaviors in brain-injured patients with different levels of consciousness during nociceptive and nonnociceptive care procedures in the ICU and to examine interrater agreement of individual behaviors as well as discriminative and criterion validation of putative pain behaviors. METHODS Brain-injured ICU patients were observed using a 40-item behavioral checklist before and during soft touch (i.e., nonnociceptive procedure), turning, and other care procedures (nociceptive) by pairs of trained raters. When possible, patients self-reported their pain on a 0-10 visual thermometer. Patients were classified into unconscious (Glasgow Coma Scale, 3<GCS≤8), altered consciousness (9≤GCS≤12), or conscious (13≤GCS≤15). RESULTS A sample of 147 patients participated (65 conscious, 56 altered consciousness, and 26 unconscious). Active behaviors (e.g., face expressions and body movements) were more frequent in conscious patients. High-percentage interrater agreement (80%-98%) was obtained for most behaviors. The total number of active behaviors was significantly higher during turning and other nociceptive procedures compared with rest (Wilcoxon = 9.873, P < 0.001) and soft touch (Wilcoxon = 9.486, P < 0.001) regardless of levels of consciousness. The strongest predictors of pain intensity (n = 33) were grimace, mouth opening, orbit tightening, eye weeping, and eyes tightly closed; these behaviors were moderately correlated with self-reported pain intensity (Spearman rho = 0.47). CONCLUSION These findings may guide the revision of existing pain scales to make their content more suited for this population.
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Affiliation(s)
- Céline Gélinas
- Ingram School of Nursing, McGill University, Montréal, Québec, Canada; Centre for Nursing Research and Lady Davis Institute, CIUSSS Centre-Ouest-Ile-de-Montréal - Jewish General Hospital, Montréal, Québec, Canada.
| | - Madalina Boitor
- Faculty of Dentistry, McGill University, Montréal, Québec, Canada; Centre for Nursing Research and Lady Davis Institute, CIUSSS Centre-Ouest-Ile-de-Montréal - Jewish General Hospital, Montréal, Québec, Canada
| | - Kathleen A Puntillo
- Physiological Nursing, University of California San Francisco, San Francisco, California, USA
| | - Caroline Arbour
- Faculty of Nursing, Université de Montréal, Montréal, Québec, Canada; Centre de recherche Hôpital du Sacré-Cœur de Montréal, CIUSSS du Nord-de-l'Île-de-Montréal, Montreal, Québec, Canada
| | | | - Michael D Cusimano
- Injury Prevention Research Office and Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Manon Choinière
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Quebec, Canada; Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - David L Streiner
- St. Joseph's Healthcare, Mountain Site, Hamilton, Ontario, Canada; Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Puntillo KA, Max A, Timsit JF, Ruckly S, Chanques G, Robleda G, Roche-Campo F, Mancebo J, Divatia JV, Soares M, Ionescu DC, Grintescu IM, Maggiore SM, Rusinova K, Owczuk R, Egerod I, Papathanassoglou EDE, Kyranou M, Joynt GM, Burghi G, Freebairn RC, Ho KM, Kaarlola A, Gerritsen RT, Kesecioglu J, Sulaj MMS, Norrenberg M, Benoit DD, Seha MSG, Hennein A, Pereira FJ, Benbenishty JS, Abroug F, Aquilina A, Monte JRC, An Y, Azoulay E. Pain distress: the negative emotion associated with procedures in ICU patients. Intensive Care Med 2018; 44:1493-1501. [PMID: 30128592 DOI: 10.1007/s00134-018-5344-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/06/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE The intensity of procedural pain in intensive care unit (ICU) patients is well documented. However, little is known about procedural pain distress, the psychological response to pain. METHODS Post hoc analysis of a multicenter, multinational study of procedural pain. Pain distress was measured before and during procedures (0-10 numeric rating scale). Factors that influenced procedural pain distress were identified by multivariable analyses using a hierarchical model with ICU and country as random effects. RESULTS A total of 4812 procedures were recorded (3851 patients, 192 ICUs, 28 countries). Pain distress scores were highest for endotracheal suctioning (ETS) and tracheal suctioning, chest tube removal (CTR), and wound drain removal (median [IQRs] = 4 [1.6, 1.7]). Significant relative risks (RR) for a higher degree of pain distress included certain procedures: turning (RR = 1.18), ETS (RR = 1.45), tracheal suctioning (RR = 1.38), CTR (RR = 1.39), wound drain removal (RR = 1.56), and arterial line insertion (RR = 1.41); certain pain behaviors (RR = 1.19-1.28); pre-procedural pain intensity (RR = 1.15); and use of opioids (RR = 1.15-1.22). Patient-related variables that significantly increased the odds of patients having higher procedural pain distress than pain intensity were pre-procedural pain intensity (odds ratio [OR] = 1.05); pre-hospital anxiety (OR = 1.76); receiving pethidine/meperidine (OR = 4.11); or receiving haloperidol (OR = 1.77) prior to the procedure. CONCLUSIONS Procedural pain has both sensory and emotional dimensions. We found that, although procedural pain intensity (the sensory dimension) and distress (the emotional dimension) may closely covary, there are certain factors than can preferentially influence each of the dimensions. Clinicians are encouraged to appreciate the multidimensionality of pain when they perform procedures and use this knowledge to minimize the patient's pain experience.
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Affiliation(s)
- Kathleen A Puntillo
- Department of Physiological Nursing, University of California, San Francisco, 2 Koret Way, Box 0610, San Francisco, CA, 94143-0610, USA.
| | - Adeline Max
- Medical Intensive Care Unit, University of Paris-Diderot, Saint Louis Hospital, Paris, France
| | - Jean-Francois Timsit
- AP-HP - Réanimation Medicale et des maladies infectieuses - Hôpital Bichat, 75018, Paris, France
| | | | - Gerald Chanques
- Department of Anesthesia and Intensive Care, Montpellier University, Hopital Saint Eloi, Montpellier, France.,PhyMedExp, INSERM, CNRS, University of Montpellier, Montpellier, France
| | - Gemma Robleda
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Ferran Roche-Campo
- Servei de Medicina intensiva, Hospital Verge de la Cinta, Tortosa, Spain
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Jigeeshu V Divatia
- Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marcio Soares
- Critical Care Departmemt and Graduate Program in Medical Sciences, Postgraduate Program, D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Daniela C Ionescu
- Department of Anesthesia and Intensive Care I, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Outcome Research Consortium, Cleveland, USA
| | - Ioana M Grintescu
- Anesthesia and Intensive Care Department, Clinical Emergency Hospital, Bucharest, Romania
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology and Intensive Care, Policlinico SS. Annunziata, Università G. d'Annunzio Chieti-Pescara, Chieti, Italy
| | - Katerina Rusinova
- Department of Anaesthesiology and Intensive Care, General University Hospital, First Faculty of Medicine of Charles University, Prague, Czech Republic
| | - Radoslaw Owczuk
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Gdansk, Poland
| | - Ingrid Egerod
- Intensive Care Unit, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Elizabeth D E Papathanassoglou
- Department of Nursing, Cyprus University of Technology, Limassol, Cyprus.,Faculty of Nursing, University of Alberta, Edmonton, Canada
| | - Maria Kyranou
- Department of Nursing, Cyprus University of Technology, Limassol, Cyprus
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Gaston Burghi
- Intensive Care Unit, Hospital Maciel, Sanatorio Americano, Montevideo, Uruguay
| | - Ross C Freebairn
- Intensive Care Services, Hawke's Bay Hospital, Hastings, New Zealand
| | - Kwok M Ho
- Department of Intensive Care Medicine and School of Population Health, Royal Perth Hospital and University of Western Australia, Perth, Australia
| | - Anne Kaarlola
- Department of Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Rik T Gerritsen
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center, Utrecht, Netherlands
| | - Miroslav M S Sulaj
- Dept. of Hematology and Transfusiology, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, University Hospital Martin, Martin, Slovakia.,Department of Anesthesiology and Intensive Medicine, Danube Hospital, Vienna, Austria
| | - Michelle Norrenberg
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | - Akram Hennein
- Consultant Critical Care, Mansoura Emergency University Hospital, Mansoura, Egypt
| | - Fernando J Pereira
- Servicio Medicina Crítica y Cuidados Intensivos, Clínica Las Américas, Medellín, Colombia
| | | | - Fekri Abroug
- Intensive Care Unit, CHU F. Bourguiba, Monastir, Tunisia
| | - Andrew Aquilina
- Department of Anaesthesia and Intensive Care, Mater Dei Hospital, Msida, Malta
| | - Julia R C Monte
- Servico Cuidados Intensivos, Hospital Santo Antonio, Centro Hospitalar do Porto, Porto, Portugal
| | - Youzhong An
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Elie Azoulay
- Medical Intensive Care Unit, University of Paris-Diderot, Saint Louis Hospital, Paris, France
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Barnes‐Daly MA, Pun BT, Harmon LA, Byrum DG, Kumar VK, Devlin JW, Stollings JL, Puntillo KA, Engel HJ, Posa PJ, Barr J, Schweickert WD, Esbrook CL, Hargett KD, Carson SS, Aldrich JM, Ely EW, Balas MC. Improving Health Care for Critically Ill Patients Using an Evidence‐Based Collaborative Approach to ABCDEF Bundle Dissemination and Implementation. Worldviews Evid Based Nurs 2018; 15:206-216. [DOI: 10.1111/wvn.12290] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2018] [Indexed: 11/30/2022]
Affiliation(s)
| | - Brenda T. Pun
- Clinical Program ManagerVanderbilt University Medical Center Nashville TN USA
| | - Lori A. Harmon
- Director QualitySociety of Critical Care Medicine Mount Prospect IL USA
| | - Diane G. Byrum
- Quality Implementation ConsultantInnovative Solutions for HealthCare Education LLC Chicago IL USA
| | - Vishakha K. Kumar
- Senior Manager, ResearchSociety of Critical Care Medicine Mount Prospect IL USA
| | - John W. Devlin
- Professor of Pharmacy, School of Pharmacy, Northeastern University, and Scientific Staff, Division of Pulmonary and Critical Care MedicineTufts Medical Center Boston MA USA
| | - Joanna L. Stollings
- Medical Intensive Care Unit Clinical Pharmacy Specialist and Pharmacist ICU Recovery Center, Department of Pharmaceutical ServicesVanderbilt University Medical Center Nashville TN USA
| | - Kathleen A. Puntillo
- Professor EmeritaSchool of Nursing, University of California San Francisco San Francisco, CA USA
| | - Heidi J. Engel
- Clinical Specialist, Department of Rehabilitative ServicesUniversity of California San Francisco CA USA
| | - Patricia J. Posa
- Quality Excellence LeaderSaint Joseph Mercy Health System Ann Arbor MI USA
| | - Juliana Barr
- Associate Professor, Department of Anesthesiology, Perioperative, and Pain MedicineStanford University School of Medicine Stanford CA USA
- Staff Anesthesiologist and Intensivist at the VA, Anesthesiology ServiceVA Palo Alto Health Care System Palo Alto CA USA
| | - William D. Schweickert
- Director, Medical Critical Care Operations, Division of Pulmonary, Allergy and Critical CarePerelman School of Medicine at the University of Pennsylvania Philadelphia PA USA
| | - Cheryl L. Esbrook
- Program Coordinator of Occupational Therapy Professional DevelopmentUniversity of Chicago Medicine Chicago IL USA
| | - Ken D. Hargett
- Director, Respiratory Care ServicesHouston Methodist Hospital Houston TX USA
| | - Shannon S. Carson
- Professor of Medicine and Division Chief, Pulmonary Diseases & Critical Care MedicineUniversity of North Carolina‐Chapel Hill Chapel Hill NC USA
| | - J. Matthew Aldrich
- Medical Director, Critical Care Medicine, Associate Clinical Professor, Anesthesia and Perioperative CareUniversity of San Francisco‐California Medical Center San Francisco CA USA
| | - E. Wesley Ely
- Professor of Medicine, Department of Medicine, Pulmonary and Critical Care and Health Services Research CenterVanderbilt University School of Medicine and The Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC) Nashville TN USA
| | - Michele C. Balas
- Associate Professor, College of Nursing, Center of Excellence in Critical and Complex CareThe Ohio State University and Nurse Scientist, The Ohio State University Wexner Medical Center Columbus OH USA
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Coombs M, Puntillo KA, Franck LS, Scruth EA, Harvey MA, Swoboda SM, Davidson JE. Implementing the SCCM Family-Centered Care Guidelines in Critical Care Nursing Practice. AACN Adv Crit Care 2018; 28:138-147. [PMID: 28592473 DOI: 10.4037/aacnacc2017766] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Family-centered care is an important component of holistic nursing practice, particularly in critical care, where the impact on families of admitted patients can be physiologically and psychologically burdensome. Family-centered care guidelines, developed by an international group of nursing, medical, and academic experts for the American College of Critical Care Medicine/Society of Critical Care Medicine, explore the evidence base in 5 key areas of family-centered care. Evidence in each of the guideline areas is outlined and recommendations are made about how critical care nurses can use this information in family-centered care practice.
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Affiliation(s)
- Maureen Coombs
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Kathleen A Puntillo
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Linda S Franck
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Elizabeth A Scruth
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Maurene A Harvey
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Sandra M Swoboda
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Judy E Davidson
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
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Schell-Chaple HM, Liu KD, Matthay MA, Puntillo KA. Rectal and Bladder Temperatures vs Forehead Core Temperatures Measured With SpotOn Monitoring System. Am J Crit Care 2018; 27:43-50. [PMID: 29292274 DOI: 10.4037/ajcc2018865] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Methods and frequency of temperature monitoring in intensive care unit patients vary widely. The recently available SpotOn system uses zero-heat-flux technology and offers a noninvasive method for continuous monitoring of core temperature of critical care patients at risk for alterations in body temperature. OBJECTIVE To evaluate agreement between and precision of a zero-heat-flux thermometry system (SpotOn) and continuous rectal and urinary bladder thermometry during fever and defervescence in adult patients in intensive care units. METHODS Prospective comparison of SpotOn vs rectal and urinary bladder thermometry in eligible patients enrolled in a randomized clinical trial on the effect of acetaminophen on core body temperature and hemodynamic status. RESULTS A total of 748 paired temperature measurements from 38 patients who had both SpotOn monitoring and either continuous rectal or continuous bladder thermometry were analyzed. Temperatures during the study were from 36.6°C to 39.9°C. The mean difference for SpotOn compared with bladder thermometry was -0.07°C (SD, 0.24°C; 95% limits of agreement, ± 0.47°C [-0.54°C, 0.40°C]). The mean difference for SpotOn compared with rectal thermometry was -0.24°C (SD, 0.29°C; 95% limits of agreement, ± 0.57°C [-0.81°C, 0.33°C]). Most differences in temperature between methods were within ± 0.5°C in both groups (96% bladder and 85% rectal). CONCLUSIONS The SpotOn thermometry system has excellent agreement and good precision and is a potential alternative for noninvasive continuous monitoring of core temperature in critical care patients, especially when alternative methods are contraindicated or not available.
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Affiliation(s)
- Hildy M. Schell-Chaple
- Hildy M. Schell-Chaple is a clinical nurse specialist and an associate professor of nursing, University of California, San Francisco Medical Center, San Francisco, California. Kathleen D. Liu is a professor of medicine and Michael A. Matthay is a professor of medicine and anesthesia, University of California, San Francisco School of Medicine, San Francisco, California. Kathleen A. Puntillo is professor emeritus, University of California, San Fran-cisco School of Nursing, San Francisco, California
| | - Kathleen D. Liu
- Hildy M. Schell-Chaple is a clinical nurse specialist and an associate professor of nursing, University of California, San Francisco Medical Center, San Francisco, California. Kathleen D. Liu is a professor of medicine and Michael A. Matthay is a professor of medicine and anesthesia, University of California, San Francisco School of Medicine, San Francisco, California. Kathleen A. Puntillo is professor emeritus, University of California, San Fran-cisco School of Nursing, San Francisco, California
| | - Michael A. Matthay
- Hildy M. Schell-Chaple is a clinical nurse specialist and an associate professor of nursing, University of California, San Francisco Medical Center, San Francisco, California. Kathleen D. Liu is a professor of medicine and Michael A. Matthay is a professor of medicine and anesthesia, University of California, San Francisco School of Medicine, San Francisco, California. Kathleen A. Puntillo is professor emeritus, University of California, San Fran-cisco School of Nursing, San Francisco, California
| | - Kathleen A. Puntillo
- Hildy M. Schell-Chaple is a clinical nurse specialist and an associate professor of nursing, University of California, San Francisco Medical Center, San Francisco, California. Kathleen D. Liu is a professor of medicine and Michael A. Matthay is a professor of medicine and anesthesia, University of California, San Francisco School of Medicine, San Francisco, California. Kathleen A. Puntillo is professor emeritus, University of California, San Fran-cisco School of Nursing, San Francisco, California
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Stotts NA, Arai SR, Cooper BA, Nelson JE, Puntillo KA. Predictors of thirst in intensive care unit patients. J Pain Symptom Manage 2015; 49:530-8. [PMID: 25116914 PMCID: PMC4324384 DOI: 10.1016/j.jpainsymman.2014.07.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 07/20/2014] [Accepted: 07/23/2014] [Indexed: 12/30/2022]
Abstract
CONTEXT Thirst is a pervasive, intense, and distressing symptom in intensive care unit (ICU) patients. Although thirst may be avoided and/or treated, scant data are available to help providers identify patients most in need. OBJECTIVES This study was designed to identify predictors of the presence, intensity, and distress of thirst in ICU patients. METHODS This descriptive cross-sectional study enrolled 353 patients from three ICUs (medical-surgical, cardiac, and neurological). To measure outcomes, patients were asked to report the presence of thirst (yes/no) and, if present, to rate its intensity and distress on zero to 10 numeric rating scales (10=worst). Predictor variables were demographic (e.g., age), treatment-related (e.g., opioids), and biological (e.g., total body water). Data were analyzed with logistic regression and truncated regression with alpha preset at 0.05. RESULTS Thirst presence was predicted by high opioid doses (≥ 50 mg), high furosemide doses (>60 mg), selective serotonin reuptake inhibitors, and low ionized calcium. Thirst intensity was predicted by patients not receiving oral fluid and having a gastrointestinal (GI) diagnosis. Thirst distress was predicted by mechanical ventilation, negative fluid balance, antihypertensive medications, and a GI or "other" diagnosis. CONCLUSION Thirst presence was predicted by selected medications (e.g., opioids). Thirst intensity and/or thirst distress were predicted by other treatments (e.g., mechanical ventilation) and medical diagnoses (e.g., GI). This is one of the first studies describing predictors of the multidimensional characteristics of thirst. Clinicians can use these data to target ICU patients whose thirst might warrant treatment.
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Affiliation(s)
- Nancy A Stotts
- University of California San Francisco, San Francisco, California, USA.
| | - Shoshana R Arai
- University of California San Francisco, San Francisco, California, USA
| | - Bruce A Cooper
- University of California San Francisco, San Francisco, California, USA
| | - Judith E Nelson
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Nelson JE, Mathews KS, Weissman DE, Brasel KJ, Campbell M, Curtis JR, Frontera JA, Gabriel M, Hays RM, Mosenthal AC, Mulkerin C, Puntillo KA, Ray DE, Weiss SP, Bassett R, Boss RD, Lustbader DR. Integration of palliative care in the context of rapid response: a report from the Improving Palliative Care in the ICU advisory board. Chest 2015; 147:560-569. [PMID: 25644909 PMCID: PMC4314822 DOI: 10.1378/chest.14-0993] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 07/01/2014] [Indexed: 01/24/2023] Open
Abstract
Rapid response teams (RRTs) can effectively foster discussions about appropriate goals of care and address other emergent palliative care needs of patients and families facing life-threatening illness on hospital wards. In this article, The Improving Palliative Care in the ICU (IPAL-ICU) Project brings together interdisciplinary expertise and existing data to address the following: special challenges for providing palliative care in the rapid response setting, knowledge and skills needed by RRTs for delivery of high-quality palliative care, and strategies for improving the integration of palliative care with rapid response critical care. We discuss key components of communication with patients, families, and primary clinicians to develop a goal-directed treatment approach during a rapid response event. We also highlight the need for RRT expertise to initiate symptom relief. Strategies including specific clinician training and system initiatives are then recommended for RRT care improvement. We conclude by suggesting that as evaluation of their impact on other outcomes continues, performance by RRTs in meeting palliative care needs of patients and families should also be measured and improved.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ross M Hays
- University of Washington School of Medicine, Seattle, WA
| | | | | | | | - Daniel E Ray
- University of California, San Francisco, San Francisco, CA
| | | | - Rick Bassett
- Lehigh Valley Health Network, Allentown, PA; Johns Hopkins University School of Medicine, Baltimore, MD
| | - Renee D Boss
- Icahn School of Medicine at Mount Sinai, New York, NY; St. Luke's Hospital, Boise, ID
| | - Dana R Lustbader
- Hofstra North Shore-Long Island Jewish School of Medicine, Hempstead, NY
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Schell-Chaple HM, Puntillo KA, Matthay MA, Liu KD. Body temperature and mortality in patients with acute respiratory distress syndrome. Am J Crit Care 2015; 24:15-23. [PMID: 25554550 DOI: 10.4037/ajcc2015320] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Little is known about the relationship between body temperature and outcomes in patients with acute respiratory distress syndrome (ARDS). A better understanding of this relationship may provide evidence for fever suppression or warming interventions, which are commonly applied in practice. OBJECTIVE To examine the relationship between body temperature and mortality in patients with ARDS. METHODS Secondary analysis of body temperature and mortality using data from the ARDS Network Fluid and Catheter Treatment Trial (n = 969). Body temperature at baseline and on study day 2, primary cause of ARDS, severity of illness, and 90-day mortality were analyzed by using multiple logistic regression. RESULTS Mean baseline temperature was 37.5°C (SD, 1.1°C; range, 27.2°C-40.7°C). At baseline, fever (≥ 38.3°C) was present in 23% and hypothermia (< 36°C) in 5% of the patients. Body temperature was a significant predictor of 90-day mortality after primary cause of ARDS and score on the Acute Physiology and Chronic Health Evaluation III were adjusted for. Higher temperature was associated with decreased mortality: for every 1°C increase in baseline temperature, the odds of death decreased by 15% (odds ratio, 0.85; 95% CI, 0.73-0.98, P = .03). When patients were divided into 5 temperature groups, mortality was lower with higher temperature (P for trend = .02). CONCLUSIONS Early in ARDS, fever is associated with improved survival rates. Fever in the acute phase response to lung injury and its relationship to recovery may be an important factor in determining patients' outcome and warrants further study.
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Affiliation(s)
- Hildy M. Schell-Chaple
- Hildy M. Schell-Chaple is a clinical nurse specialist and PhD candidate at the University of California, San Francisco (UCSF) School of Nursing. Kathleen A. Puntillo is a professor emerita at the UCSF School of Nursing. Michael A. Matthay is a professor of medicine and anesthesia and Kathleen D. Liu is an associate professor at the UCSF School of Medicine
| | - Kathleen A. Puntillo
- Hildy M. Schell-Chaple is a clinical nurse specialist and PhD candidate at the University of California, San Francisco (UCSF) School of Nursing. Kathleen A. Puntillo is a professor emerita at the UCSF School of Nursing. Michael A. Matthay is a professor of medicine and anesthesia and Kathleen D. Liu is an associate professor at the UCSF School of Medicine
| | - Michael A. Matthay
- Hildy M. Schell-Chaple is a clinical nurse specialist and PhD candidate at the University of California, San Francisco (UCSF) School of Nursing. Kathleen A. Puntillo is a professor emerita at the UCSF School of Nursing. Michael A. Matthay is a professor of medicine and anesthesia and Kathleen D. Liu is an associate professor at the UCSF School of Medicine
| | - Kathleen D. Liu
- Hildy M. Schell-Chaple is a clinical nurse specialist and PhD candidate at the University of California, San Francisco (UCSF) School of Nursing. Kathleen A. Puntillo is a professor emerita at the UCSF School of Nursing. Michael A. Matthay is a professor of medicine and anesthesia and Kathleen D. Liu is an associate professor at the UCSF School of Medicine
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Puntillo KA, Max A, Timsit JF, Vignoud L, Chanques G, Robleda G, Roche-Campo F, Mancebo J, Divatia JV, Soares M, Ionescu DC, Grintescu IM, Vasiliu IL, Maggiore SM, Rusinova K, Owczuk R, Egerod I, Papathanassoglou EDE, Kyranou M, Joynt GM, Burghi G, Freebairn RC, Ho KM, Kaarlola A, Gerritsen RT, Kesecioglu J, Sulaj MMS, Norrenberg M, Benoit DD, Seha MSG, Hennein A, Periera FJ, Benbenishty JS, Abroug F, Aquilina A, Monte JRC, An Y, Azoulay E. Determinants of procedural pain intensity in the intensive care unit. The Europain® study. Am J Respir Crit Care Med 2014; 189:39-47. [PMID: 24262016 DOI: 10.1164/rccm.201306-1174oc] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Intensive care unit (ICU) patients undergo several diagnostic and therapeutic procedures every day. The prevalence, intensity, and risk factors of pain related to these procedures are not well known. OBJECTIVES To assess self-reported procedural pain intensity versus baseline pain, examine pain intensity differences across procedures, and identify risk factors for procedural pain intensity. METHODS Prospective, cross-sectional, multicenter, multinational study of pain intensity associated with 12 procedures. Data were obtained from 3,851 patients who underwent 4,812 procedures in 192 ICUs in 28 countries. MEASUREMENTS AND MAIN RESULTS Pain intensity on a 0-10 numeric rating scale increased significantly from baseline pain during all procedures (P < 0.001). Chest tube removal, wound drain removal, and arterial line insertion were the three most painful procedures, with median pain scores of 5 (3-7), 4.5 (2-7), and 4 (2-6), respectively. By multivariate analysis, risk factors independently associated with greater procedural pain intensity were the specific procedure; opioid administration specifically for the procedure; preprocedural pain intensity; preprocedural pain distress; intensity of the worst pain on the same day, before the procedure; and procedure not performed by a nurse. A significant ICU effect was observed, with no visible effect of country because of its absorption by the ICU effect. Some of the risk factors became nonsignificant when each procedure was examined separately. CONCLUSIONS Knowledge of risk factors for greater procedural pain intensity identified in this study may help clinicians select interventions that are needed to minimize procedural pain. Clinical trial registered with www.clinicaltrials.gov (NCT 01070082).
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Affiliation(s)
- Kathleen A Puntillo
- 1 Department of Physiological Nursing, University of California, San Francisco, San Francisco, California
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21
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McAdam JL, Nelson JE, Puntillo KA. Regret. Intensive Care Med 2013; 40:436-7. [PMID: 24271028 DOI: 10.1007/s00134-013-3160-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 11/08/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Jennifer L McAdam
- Samuel Merritt University, 3100 Telegraph Ave, Oakland, CA, 94609, USA
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Abstract
Thirst, as a symptom, has long been considered the most prevalent clinical complaint patients voice in healthcare settings. Yet, rarely have researchers examined thirst by its correlation with physiologic factors. This review was undertaken to examine the relationships between thirst ratings and factors mediating its primary physiologic correlates: plasma osmolality (pOsm) and arginine vasopressin peptide (AVP). A literature search was undertaken to identify clinical studies in human subjects that investigated the relationship of thirst to specific physiologic thirst-related correlates and associated thirst mediators. Thirst was induced in 17 selected clinical studies by hyperosmolar infusion, through water deprivation or exercise weight-loss regimens. Positive linear relationships between the subjects' thirst ratings and rising serum pOsm levels confirmed the presence of intact osmotic thirst drives. However, there were significant variations in normal compensatory rises in AVP levels that followed the rises in plasma osmolality after the subjects were exposed to cold, physical pre-conditioning and water immersion tests. Notably, older adults in the studies reported diminished thirst ratings. Weak correlations suggest that angiotensin II may play only a minor role in thirst mediation. Atrial natriuretic hormone's inhibitory effect on thirst was inconsistent. Findings indicated that older adults are at higher risk for profound dehydration due to sensory deficits along with failure to correct volume losses. The thirst trials results support the close correlation between serum pOsm values and patients' thirst ratings, with the exception of the older adult.
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Affiliation(s)
- Shoshana R Arai
- Department of Physiological Nursing, San Francisco School of Nursing, University of California, San Francisco, CA, USA
| | - Alice Butzlaff
- Department of Physiological Nursing, San Francisco School of Nursing, University of California, San Francisco, CA, USA
| | - Nancy A Stotts
- Department of Physiological Nursing, San Francisco School of Nursing, University of California, San Francisco, CA, USA
| | - Kathleen A Puntillo
- Department of Physiological Nursing, San Francisco School of Nursing, University of California, San Francisco, CA, USA
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Abstract
Open visitation has been highly recommended by critical care groups but is not prevalent in practice. Here we discuss the present study on current visitation practices in US ICUs and discuss several factors affecting open visitation. We conclude with suggestions on achieving more liberal visitation practices.
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McAdam JL, Fontaine DK, White DB, Dracup KA, Puntillo KA. Psychological symptoms of family members of high-risk intensive care unit patients. Am J Crit Care 2012; 21:386-93; quiz 394. [PMID: 23117902 DOI: 10.4037/ajcc2012582] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Family members of patients in intensive care are at increased risk for psychological symptoms. OBJECTIVES To compare levels of posttraumatic stress disorder, anxiety, and depression during and 3 months after the intensive care experience in family members of patients at high risk for dying and to determine if differences were related to the patient's final disposition. METHODS Longitudinal descriptive study of 41 family members in 3 tertiary care intensive care units. RESULTS By repeated-measures analysis of variance, family members' levels of posttraumatic stress disorder were significantly lower (P = .01) at 3 months after (mean score, 1.27; SD, 0.86) than during (mean, 1.61; SD, 0.81) the experience. Mean anxiety and depression scores were significantly lower (P < .001) after (anxiety: 7.35; SD, 3.91; depression: 5.63; SD, 4.58) than during (anxiety: 11.5; SD, 4.88; depression: 9.51; SD, 4.31) the experience. Scores for posttraumatic stress disorder, anxiety, and depression did not differ significantly between family members of patients who died and family members of patients who survived. Yet, all 13 family members of deceased patients and 42% of the total sample of 41 had traumatic stress scores of 1.5 or greater. Among the total sample, 44% had significant anxiety, and 27% were depressed. CONCLUSION Family members' symptoms of posttraumatic stress disorder, anxiety, and depression significantly decreased 3 months after the intensive care experience and did not differ according to the patients' final disposition. However, many family members still had significant risk for posttraumatic stress disorder and borderline anxiety and depression at 3 months.
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Affiliation(s)
- Jennifer L McAdam
- Samuel Merritt University, School of Nursing, Oakland, California 94609, USA.
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Figueroa-Ramos MI, Arroyo-Novoa CM, Padilla G, Rodríguez-Ortiz P, Cooper BA, Puntillo KA. Feasibility of a sedation wake-up trial and spontaneous breathing trial in critically ill trauma patients: a secondary analysis. Intensive Crit Care Nurs 2012; 29:20-7. [PMID: 22705052 DOI: 10.1016/j.iccn.2012.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 04/05/2012] [Accepted: 05/04/2012] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To determine the feasibility of conducting a sedation wake-up trial (SWT) plus a spontaneous breathing trial (SBT) in critically ill trauma patients based on the ability to implement the combined intervention; to measure and describe patients' physiological responses; and to maintain patient safety. METHODS A secondary analysis of the intervention group from a trial of 20 mechanically ventilated patients receiving SWT plus SBT in a trauma-intensive care unit. RESULTS Patients passed 67% of the 39 SWTs performed; those who failed presented RASS scores of +1 and +2 (70%), tachycardia (15%) or ventilator asynchrony (15%). Eighteen patients tolerated their first SBT, and after the second SBT, more than half of the patients were discontinued from the mechanical ventilator. A significant increase from the beginning to the end of the SWT was found in heart rate (p=.021), respiratory rate (p=.043) and systolic blood pressure (p=.04). Although these measures increased significantly, their overall mean did not increase by 20%. CONCLUSION SWT plus SBT was well tolerated and successfully implemented. Our data showed that it is not necessary to withhold continuous-infusion analgesia during the SWT.
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Lustbader DR, Nelson JE, Weissman DE, Hays RM, Mosenthal AC, Mulkerin C, Puntillo KA, Ray DE, Bassett R, Boss RD, Brasel KJ, Campbell ML, Cortez TB, Curtis JR. Physician reimbursement for critical care services integrating palliative care for patients who are critically ill. Chest 2012; 141:787-792. [PMID: 22396564 DOI: 10.1378/chest.11-2012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Patients with advanced illness often spend time in an ICU, while nearly one-third of patients with advanced cancer who receive Medicare die in hospitals, often with failed ICU care. For most, death occurs following the withdrawal or withholding of life-sustaining treatments. The integration of palliative care is essential for high-quality critical care. Although palliative care specialists are becoming increasingly available, intensivists and other physicians are also expected to provide basic palliative care, including symptom treatment and communication about goals of care. Patients who are critically ill are often unable to make decisions about their care. In these situations, physicians must meet with family members or other surrogates to determine appropriate medical treatments. These meetings require clinical expertise to ensure that patient values are explored for medical decision making about therapeutic options, including palliative care. Meetings with families take time. Issues related to the disease process, prognosis, and treatment plan are complex, and decisions about the use or limitation of intensive care therapies have life-or-death implications. Inadequate reimbursement for physician services may be a barrier to the optimal delivery of high-quality palliative care, including effective communication. Appropriate documentation of time spent integrating palliative and critical care for patients who are critically ill can be consistent with the Current Procedural Terminology codes (99291 and 99292) for critical care services. The purpose of this article is to help intensivists and other providers understand the circumstances in which integration of palliative and critical care meets the definition of critical care services for billing purposes.
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Affiliation(s)
- Dana R Lustbader
- Division of Palliative Medicine, North Shore University Hospital, Manhasset, NY.
| | - Judith E Nelson
- Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - David E Weissman
- Department of Internal Medicine, Medical College of Wisconsin Milwaukee, WI
| | - Ross M Hays
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
| | - Anne C Mosenthal
- Division of Critical Care and Palliative Care, University of Medicine and Dentistry, Newark, NJ
| | - Colleen Mulkerin
- Department of Palliative Medicine, Hartford Hospital, Hartford, CT
| | - Kathleen A Puntillo
- School of Nursing, University of California, San Francisco, San Francisco, CA
| | - Daniel E Ray
- Critical Care Department, Lehigh Valley Health Network, Allentown, PA
| | | | - Renee D Boss
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MA
| | - Karen J Brasel
- Department of Surgery, Froedtert Hospital, Milwaukee, WI
| | | | - Therese B Cortez
- Department of Palliative Care, Veterans Integrated Service Network 3, New York, NY
| | - J Randall Curtis
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, Seattle, WA
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Krimshtein NS, Luhrs CA, Puntillo KA, Cortez TB, Livote EE, Penrod JD, Nelson JE. Training nurses for interdisciplinary communication with families in the intensive care unit: an intervention. J Palliat Med 2011; 14:1325-32. [PMID: 22132740 DOI: 10.1089/jpm.2011.0225] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Critical care nurse communication training has largely been limited to didactic materials, interactive training for nurse supervisors, or brief participatory learning programs within the context of comprehensive end-of-life care educational seminars. Preliminary evidence suggests that an interactive approach can also be effective in communication skills training for intensive care unit (ICU) nurses. METHODS We implemented a 1-day educational intervention in five acute care hospitals within Veterans Integrated Service Network (VISN) 3 (New York-New Jersey region) of the Department of Veterans Affairs and focused solely on communication skills and targeted specifically to nurses providing bedside care for critically ill patients. A "learner centered" approach to skills training that has several integral components was employed. AMONG THESE ARE: a cognitive, evidence-based foundation upon which to build new skills; a method such as role-play that allows participants to practice newly learned skills; and an affective component, during which trainees can freely discuss their impressions of the exercise or explore difficulties that may have been encountered. Before and after the program we conducted a detailed assessment of participants' self-rated communication skills and of the techniques and materials we used. RESULTS AND CONCLUSIONS Post-program responses documented significant improvement in self-evaluated skills for each of the core tasks we assessed. Evidence suggests that communication with patients and families in the ICU can be most effectively approached in an interdisciplinary way. For nurses to fully realize their potential for optimal communication as members of the multidisciplinary team, they must be equipped with the necessary skills. We believe this new program helps to expand the range of approaches for training nurses in essential communication skills.
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Affiliation(s)
- Nina S Krimshtein
- Mount Sinai School of Medicine, Division of Pulmonary and Critical Care, New York, New York 10029, USA
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Nelson JE, Cortez TB, Curtis JR, Lustbader DR, Mosenthal AC, Mulkerin C, Ray DE, Bassett R, Boss RD, Brasel KJ, Campbell ML, Weissman DE, Puntillo KA. Integrating Palliative Care in the ICU: The Nurse in a Leading Role. J Hosp Palliat Nurs 2011; 13:89-94. [PMID: 21874122 PMCID: PMC3162372 DOI: 10.1097/njh.0b013e318203d9ff] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Palliative care is increasingly recognized as an integral component of comprehensive intensive care for all critically ill patients, regardless of prognosis, and for their families. Here we discuss the key role that nurses can and must continue to play in making this evidence-based paradigm a clinical reality across a broad range of ICUs. We review the contributions of nurses to implementation of ICU safety initiatives as a model that can be applied to ICU palliative care integration. We focus on the importance of nursing involvement in design and application of work processes that facilitate this integration in a systematic way, including processes that ensure the participation of nurses in discussions and decision making with families about care goals. We suggest ways that nurses can help to operationalize an integrated approach to palliative care in the ICU and to define their own essential role in a successful, sustainable ICU palliative care improvement effort. Finally, we identify resources including The IPAL-ICU Project™, a new initiative by the Center to Advance Palliative Care that can assist nurses and other healthcare professionals to move such efforts forward in diverse critical care settings.
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Affiliation(s)
- Judith E Nelson
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine and Hertzberg Palliative Care Institute, Project Director, The IPAL-ICU Project™, Center to Advance Palliative Care, Mount Sinai School of Medicine, New York, NY
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Anderson WG, Winters K, Arnold RM, Puntillo KA, White DB, Auerbach AD. Studying physician-patient communication in the acute care setting: the hospitalist rapport study. Patient Educ Couns 2011; 82:275-9. [PMID: 20444569 PMCID: PMC3025053 DOI: 10.1016/j.pec.2010.04.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 04/02/2010] [Accepted: 04/07/2010] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To assess the feasibility of studying physician-patient communication in the acute care setting. METHODS We recruited hospitalist physicians and patients from two hospitals within a university system and audio-recorded their first encounter. Recruitment, data collection, and challenges encountered were tracked. RESULTS Thirty-two physicians consented (rate 91%). Between August 2008 and March 2009, 441 patients were referred, 210 (48%) were screened, and 119 (66% of 179 eligible) consented. We audio-recorded encounters of 80 patients with 27 physicians. Physicians' primary concern about participation was interference with their workflow. Addressing their concerns and building the protocol around their schedules facilitated participation. Challenges unique to the acute care setting were: (1) extremely limited time for patient identification, screening, and enrollment during which patients were ill and busy with clinical care activities and (2) little advance knowledge of when physician-patient encounters would occur. Employing a full-time study coordinator mitigated these challenges. CONCLUSION Physician concerns for participating in communication studies are similar in ambulatory and acute care settings. The acute care setting presents novel challenges for patient recruitment and data collection. PRACTICE IMPLICATIONS These methods should be used to study provider-patient communication in acute care settings. Future work should test strategies to increase patient enrollment.
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Affiliation(s)
- Wendy G Anderson
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CA 94143-0903, USA.
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Abstract
BACKGROUND The epidemiology of pain during the last years of life has not been well described. OBJECTIVE To describe the prevalence and correlates of pain during the last 2 years of life. DESIGN Observational study. Data from participants who died while enrolled in the Health and Retirement Study were analyzed. The survey interview closest to death was used. Each participant or proxy was interviewed once in the last 24 months of life and was classified into 1 of 24 cohorts on the basis of the number of months between the interview and death. The relationship between time before death and pain was modeled and was adjusted for age, sex, race or ethnicity, education level, net worth, income, terminal diagnosis category, presence of arthritis, and proxy status. SETTING The Health and Retirement Study, a nationally representative survey of community-living older adults (1994 to 2006). PARTICIPANTS Older adult decedents. MEASUREMENTS Clinically significant pain, as indicated by a report that the participant was "often troubled" by pain of at least moderate severity. RESULTS The sample included 4703 decedents. Mean age (SD) of participants was 75.7 years (SD, 10.8); 83.1% were white, 10.7% were black, 4.7% were Hispanic; and 52.3% were men. The adjusted prevalence of pain 24 months before death was 26% (95% CI, 23% to 30%). The prevalence remained flat until 4 months before death (28% [CI, 25% to 32%]), then it increased, reaching 46% (CI, 38% to 55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis versus 26% among patients without arthritis (P < 0.001) and did not differ by terminal diagnosis category (cancer [45%], heart disease [48%], frailty [50%], sudden death [42%], or other causes [47%]; P = 0.195). LIMITATION Data are cross-sectional; 19% of responses were from proxies; and information about cause, location, and treatment of pain was not available. CONCLUSION Although the prevalence of pain increases in the last 4 months of life, pain is present in more than one quarter of elderly persons during the last 2 years of life. Arthritis is strongly associated with pain at the end of life. PRIMARY FUNDING SOURCE National Institute on Aging, National Center for Research Resources, National Institute on Musculoskeletal and Skin Diseases, and National Palliative Care Research Center.
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Affiliation(s)
- Alexander K Smith
- University of California, San Francisco, Veterans Affairs Medical Center, 94121, USA.
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Abstract
BACKGROUND The epidemiology of pain during the last years of life has not been well described. OBJECTIVE To describe the prevalence and correlates of pain during the last 2 years of life. DESIGN Observational study. Data from participants who died while enrolled in the Health and Retirement Study were analyzed. The survey interview closest to death was used. Each participant or proxy was interviewed once in the last 24 months of life and was classified into 1 of 24 cohorts on the basis of the number of months between the interview and death. The relationship between time before death and pain was modeled and was adjusted for age, sex, race or ethnicity, education level, net worth, income, terminal diagnosis category, presence of arthritis, and proxy status. SETTING The Health and Retirement Study, a nationally representative survey of community-living older adults (1994 to 2006). PARTICIPANTS Older adult decedents. MEASUREMENTS Clinically significant pain, as indicated by a report that the participant was "often troubled" by pain of at least moderate severity. RESULTS The sample included 4703 decedents. Mean age (SD) of participants was 75.7 years (SD, 10.8); 83.1% were white, 10.7% were black, 4.7% were Hispanic; and 52.3% were men. The adjusted prevalence of pain 24 months before death was 26% (95% CI, 23% to 30%). The prevalence remained flat until 4 months before death (28% [CI, 25% to 32%]), then it increased, reaching 46% (CI, 38% to 55%) in the last month of life. The prevalence of pain in the last month of life was 60% among patients with arthritis versus 26% among patients without arthritis (P < 0.001) and did not differ by terminal diagnosis category (cancer [45%], heart disease [48%], frailty [50%], sudden death [42%], or other causes [47%]; P = 0.195). LIMITATION Data are cross-sectional; 19% of responses were from proxies; and information about cause, location, and treatment of pain was not available. CONCLUSION Although the prevalence of pain increases in the last 4 months of life, pain is present in more than one quarter of elderly persons during the last 2 years of life. Arthritis is strongly associated with pain at the end of life. PRIMARY FUNDING SOURCE National Institute on Aging, National Center for Research Resources, National Institute on Musculoskeletal and Skin Diseases, and National Palliative Care Research Center.
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Affiliation(s)
- Alexander K Smith
- University of California, San Francisco, Veterans Affairs Medical Center, 94121, USA.
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Nelson JE, Bassett R, Boss RD, Brasel KJ, Campbell ML, Cortez TB, Curtis JR, Lustbader DR, Mulkerin C, Puntillo KA, Ray DE, Weissman DE. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU Project (Improving Palliative Care in the ICU). Crit Care Med 2010; 38:1765-72. [PMID: 20562699 PMCID: PMC3267548 DOI: 10.1097/ccm.0b013e3181e8ad23] [Citation(s) in RCA: 206] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings. DATA SOURCES We searched the MEDLINE database from inception to April 2010 for all English language articles using the terms "intensive care," "critical care," or "ICU" and "palliative care"; we also hand-searched reference lists and author files. Based on review and synthesis of these data and the experiences of our interdisciplinary expert Advisory Board, we prepared this consensus report. DATA EXTRACTION AND SYNTHESIS We critically reviewed the existing data with a focus on models that have been used to structure clinical initiatives to enhance palliative care for critically ill patients in intensive care units and their families. CONCLUSIONS There are two main models for intensive care unit-palliative care integration: 1) the "consultative model," which focuses on increasing the involvement and effectiveness of palliative care consultants in the care of intensive care unit patients and their families, particularly those patients identified as at highest risk for poor outcomes; and 2) the "integrative model," which seeks to embed palliative care principles and interventions into daily practice by the intensive care unit team for all patients and families facing critical illness. These models are not mutually exclusive but rather represent the ends of a spectrum of approaches. Choosing an overall approach from among these models should be one of the earliest steps in planning an intensive care unit-palliative care initiative. This process entails a careful and realistic assessment of available resources, attitudes of key stakeholders, structural aspects of intensive care unit care, and patterns of local practice in the intensive care unit and hospital. A well-structured intensive care unit-palliative care initiative can provide important benefits for patients, families, and providers.
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Affiliation(s)
- Judith E Nelson
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine and Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, New York, NY, USA.
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Figueroa-Ramos MI, Arroyo-Novoa CM, Lee KA, Padilla G, Puntillo KA. Sleep and delirium in ICU patients: a review of mechanisms and manifestations. Intensive Care Med 2009; 35:781-95. [PMID: 19165463 DOI: 10.1007/s00134-009-1397-4] [Citation(s) in RCA: 159] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2008] [Accepted: 11/12/2008] [Indexed: 12/27/2022]
Abstract
Sleep deprivation and delirium are conditions commonly encountered in intensive care unit patients. Sleep in these patients is characterized by sleep fragmentation, an increase in light sleep, and a decrease of both slow wave sleep and rapid eye movement sleep. The most common types of delirium in this population are hypoactive and mixed-type. Knowledge about the mechanisms of sleep and delirium has evolved over time, but these phenomena are not yet well understood. What is known, however, is that different areas in the brainstem transmit information to the thalamus and cortex necessary for sleep-wake regulation. Delirium is related to an imbalance in the synthesis, release, and inactivation of some neurotransmitters, particularly acetylcholine and dopamine. The relationship between sleep deprivation and delirium has been studied for many years and has been viewed as reciprocal. The link between them may be ascribed to shared mechanisms. An imbalance in neurotransmitters as well as alteration of melatonin production may contribute to the pathogenesis of both phenomena. A better understanding of the mechanisms and factors that contribute to sleep deprivation and delirium can guide the development of new methods and models for prevention and treatment of these problems and consequently improve patient outcomes.
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Affiliation(s)
- Milagros I Figueroa-Ramos
- School of Nursing, University of Puerto Rico, Medical Sciences Campus, PO Box 365067, San Juan, Puerto Rico 00936-5067.
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Gélinas C, Harel F, Fillion L, Puntillo KA, Johnston CC. Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. J Pain Symptom Manage 2009; 37:58-67. [PMID: 18599262 DOI: 10.1016/j.jpainsymman.2007.12.022] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Revised: 12/21/2007] [Accepted: 01/02/2008] [Indexed: 11/30/2022]
Abstract
A repeated measure design was used to evaluate additional psychometric qualities (sensitivity and specificity) of the Critical-Care Pain Observation Tool (CPOT), a previously validated tool, in intubated intensive care unit (ICU) adults after cardiac surgery recruited in a university cardiology health center in Canada. Patients were evaluated while conscious and intubated (n=99/105), and extubated (n=105). For each of these two testing periods, patients were evaluated using the CPOT at rest (pre-exposure), during a nociceptive procedure-turning (exposure), and 20 minutes after the procedure (postexposure). The patients' self-reports of pain were obtained while intubated and extubated. During the nociceptive exposure, the CPOT had a sensitivity of 86%, a specificity of 78%, a positive likelihood ratio (LR(+)) of 3.87 (1.63-9.23), and a negative LR (LR(-)) of 0.18 (0.09-0.33) and was effective for the screening of pain. It also showed good specificity (83% and 97%) but lower sensitivity (47% and 63%) during nonexposure conditions. The CPOT cutoff score was >2 during the nociceptive exposure. After extubation, patients' self-reports of pain intensity were associated with the positive CPOT cutoff score previously determined. The CPOT adequately classified most of the patients with severe pain. The CPOT seems to be a useful tool to detect pain in intubated postoperative ICU adults, especially during a nociceptive procedure. Sensitivity and specificity of the CPOT need to be further explored during other nociceptive procedures and with different critically ill populations.
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Affiliation(s)
- Céline Gélinas
- School of Nursing, McGill University, Montreal, QuebecH3A 2A7, Canada.
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Gélinas C, Fillion L, Puntillo KA. Item selection and content validity of the Critical-Care Pain Observation Tool for non-verbal adults. J Adv Nurs 2009; 65:203-16. [DOI: 10.1111/j.1365-2648.2008.04847.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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McAdam JL, Arai S, Puntillo KA. Unrecognized contributions of families in the intensive care unit. Intensive Care Med 2008; 34:1097-101. [PMID: 18369593 DOI: 10.1007/s00134-008-1066-z] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Accepted: 02/07/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To describe the contributions to care that family members perform while their loved one is at high risk of dying in the intensive care unit. DESIGN Exploratory, descriptive analysis. SETTING Two intensive care units at a tertiary medical center in the western United States. PARTICIPANTS Through purposive sampling, 25 family members of 24 ICU patients at high risk of dying participated in the study. INTERVENTIONS None. MEASUREMENTS AND RESULTS A qualitative, descriptive technique was used for data analysis. Three independent raters coded transcripts of audiotaped interviews with family members about their experiences in the ICU. Recurring themes were categorized into roles that family members take on while their loved one is in the ICU. These work roles consisted of active presence, patient protector, facilitator, historian, coach, and voluntary caregiver. CONCLUSIONS Family members are important to patient care in the ICU. They perform multiple roles that are often not valued or go unrecognized by ICU health care providers. More support and appreciation of family members' contributions to care may provide families opportunities for intimacy and promote a sense of belonging in the highly technical environment of an ICU.
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Affiliation(s)
- Jennifer L McAdam
- Department of Physiological Nursing, School of Nursing, University of California-San Francisco, San Francisco, CA 94143-0610, USA.
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Arroyo-Novoa CM, Figueroa-Ramos MI, Puntillo KA, Stanik-Hutt J, Thompson CL, White C, Wild LR. Pain related to tracheal suctioning in awake acutely and critically ill adults: A descriptive study. Intensive Crit Care Nurs 2008; 24:20-7. [PMID: 17689249 DOI: 10.1016/j.iccn.2007.05.002] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2006] [Revised: 05/10/2007] [Accepted: 05/16/2007] [Indexed: 11/30/2022]
Abstract
The purpose of this secondary data analysis of findings from a larger procedural pain study was to examine several factors related to pain during tracheal suctioning. In addition to tracheal suctioning, other procedures studied included turning, wound drain removal, femoral catheter removal, placement of a central venous catheter, and wound dressing change. A total of 755 patients underwent the tracheal suctioning procedure that was performed primarily in intensive care units (93%). A 0-10 numeric rating scale, a behavioural observation tool, and a modified McGill Pain Questionnaire-Short Form were used for pain assessment. Pain intensity scores were significantly greater during the tracheal suctioning procedure (M=3.96, S.D.=3.3) than prior to (M=2.14, S.D.=2.8) or after (M=1.98, S.D.=2.7) tracheal suctioning. Few patients received analgesics prior to or during the procedure. Surgical, younger, and non-white patients reported higher pain intensities. Although mean pain intensity during tracheal suctioning was mild, almost the half of the patients reported moderate-to-severe pain. Individualized pain management must be performed by healthcare providers in order to respond to patients' needs as they undergo painful procedures such as tracheal suctioning.
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Summer GJ, Puntillo KA, Miaskowski C, Green PG, Levine JD. Burn injury pain: the continuing challenge. J Pain 2007; 8:533-48. [PMID: 17434800 DOI: 10.1016/j.jpain.2007.02.426] [Citation(s) in RCA: 177] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Revised: 01/22/2007] [Accepted: 02/08/2007] [Indexed: 01/05/2023]
Abstract
UNLABELLED The development of more effective methods of relieving pain associated with burn injury is a major unmet medical need. Not only is acute burn injury pain a source of immense suffering, but it has been linked to debilitating chronic pain and stress-related disorders. Although pain management guidelines and protocols have been developed and implemented, unrelieved moderate-to-severe pain continues to be reported after burn injury. One reason for this is that the intensity of pain associated with wound care and rehabilitation therapy, the major source of severe pain in this patient population, varies widely over the 3 phases of burn recovery, making it difficult to estimate analgesic requirements. The effects of opioids, the most commonly administered analgesics for burn injury procedural pain, are difficult to gauge over the course of burn recovery because the need for an opioid may change rapidly, resulting in the overmedication or undermedication of burn-injured patients. Understanding the mechanisms that contribute to the intensity and variability of burn injury pain over time is crucial to its proper management. We provide an overview of the types of pain associated with a burn injury, describe how these different types of pain interfere with the phases of burn recovery, and summarize pharmacologic pain management strategies across the continuum of burn care. We conclude with a discussion and suggestions for improvement. Rational management, based on the underlying mechanisms that contribute to the intensity and variability of burn injury pain, is in its infancy. The paucity of information highlights the need for research that explores and advances the identification of mechanisms of acute and chronic burn injury pain. PERSPECTIVE Researchers continue to report that burn pain is undertreated. This review examines burn injury pain management across the phases of burn recovery, emphasizing 3 types of pain that require separate assessment and management. It provides insights and suggestions for future research directions to address this significant clinical problem.
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Affiliation(s)
- Gretchen J Summer
- Department of Physiological Nursing, School of Nursing, University of California-San Francisco, San Francisco, California 94143, USA.
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Summer GJ, Puntillo KA, Miaskowski C, Dina OA, Green PG, Levine JD. TrkA and PKC-epsilon in thermal burn-induced mechanical hyperalgesia in the rat. J Pain 2007; 7:884-91. [PMID: 17157774 DOI: 10.1016/j.jpain.2006.04.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2005] [Revised: 04/12/2006] [Accepted: 04/12/2006] [Indexed: 11/23/2022]
Abstract
UNLABELLED Although mechanical hyperalgesia associated with medical procedures is the major source of severe pain in burn-injured patients, little is known about its underlying mechanism. One reason for this has been the lack of a model for mechanical hyperalgesia at the site of injury. We have modified an established partial-thickness burn model in the rat to produce long-lasting primary mechanical hyperalgesia, which is present from the first measurement at 0.5 h, reaches a maximum at 3 days, and is still significant after 7 days. Because nerve growth factor (NGF), which is elevated in burn-injured tissue, produces mechanical hyperalgesia and activates protein kinase C (PKC)-epsilon, a key mediator in inflammatory and neuropathic pain, we used this model to evaluate the role of the NGF receptor, tyrosine-receptor kinase A (TrkA), and PKC-epsilon in burn-induced primary mechanical hyperalgesia. Intrathecal administration of antisense oligodeoxynucleotides to TrkA and PKC-epsilon, starting 3 days before inducing a burn injury, caused dose-related decrease of burn-induced primary mechanical hyperalgesia. In addition, intradermal injection of a PKC-epsilon-selective inhibitor eliminated hyperalgesia. Our model provides a method to elucidate the underlying mechanism of burn-injury pain as well as to screen for targets for novel analgesic treatments of this important clinical condition. PERSPECTIVE This manuscript presents the first model of thermal injury-induced mechanical hyperalgesia which mimics prolonged duration of clinical burn injury pain. We also perform proof of concept experiments demonstrating that our model provides a method to elucidate the mechanism of this important clinical condition.
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Affiliation(s)
- Gretchen J Summer
- Department of Physiological Nursing, School of Nursing, University of California, San Francisco, USA.
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Puntillo KA, McAdam JL. Communication between physicians and nurses as a target for improving end-of-life care in the intensive care unit: Challenges and opportunities for moving forward. Crit Care Med 2006; 34:S332-40. [PMID: 17057595 DOI: 10.1097/01.ccm.0000237047.31376.28] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Our objective was to discuss obstacles and barriers to effective communication and collaboration regarding end-of-life issues between intensive care unit nurses and physicians. To evaluate practical interventions for improving communication and collaboration, we undertook a systematic literature review. An increase in shared decision making can result from a better understanding and respect for the perspectives and burdens felt by other caregivers. Intensive care unit nurses value their contributions to end-of-life decision making and want to have a more active role. Increased collaboration and communication can result in more appropriate care and increased physician/nurse, patient, and family satisfaction. Recommendations for improvement in communication between intensive care unit physicians and nurses include use of joint grand rounds, patient care seminars, and interprofessional dialogues. Communication interventions such as use of daily rounds forms, communication training, and a collaborative practice model have shown positive results. When communication is clear and constructive and practice is truly collaborative, the end-of-life care provided to intensive care unit patients and families by satisfied and engaged professionals will improve markedly.
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Affiliation(s)
- Kathleen A Puntillo
- Department of Physiological Nursing, University of California, San Francisco, California, USA
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Nelson JE, Angus DC, Weissfeld LA, Puntillo KA, Danis M, Deal D, Levy MM, Cook DJ. End-of-life care for the critically ill: A national intensive care unit survey*. Crit Care Med 2006; 34:2547-53. [PMID: 16932230 DOI: 10.1097/01.ccm.0000239233.63425.1d] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE One in five Americans dies following treatment in an intensive care unit (ICU), and evidence indicates the need to improve end-of-life care for ICU patients. We conducted this study to elicit the views and experiences of ICU directors regarding barriers to optimal end-of-life care and to identify the type, availability, and perceived benefit of specific strategies that may improve this care. DESIGN Self-administered mail survey. SETTING Six hundred intensive care units. PARTICIPANTS A random, nationally representative sample of nursing and physician directors of 600 adult ICUs in the United States. INTERVENTIONS Mail survey. MEASUREMENTS AND MAIN RESULTS We asked participants about barriers to end-of-life care (1 = huge to 5 = not at all a barrier), perceived benefit of strategies to improve end-of-life care, and availability of these strategies. From 468 ICUs (78.0% of sample), 590 ICU directors participated (406 nurses [65.1% response] and 184 physicians [31.7% response]). Respondents had a mean of 16.6 yrs (sd 7.6 yrs) of ICU experience. Important barriers to better end-of-life care included patient/family factors, including unrealistic patient/family expectations 2.5 (1.0), inability of patients to participate in discussions 2.7 (0.9), and lack of advance directives 2.9 (1.0); clinician factors, which included insufficient physician training in communication 2.9 (1.1) and competing demands on physicians' time 3.0 (1.1); and institution/ICU factors, such as suboptimal space for family meetings 3.5 (1.2) and lack of a palliative care service 3.4 (1.2). More than 80% of respondents rated 14 of 14 strategies as likely to improve end-of-life care, including trainee role modeling by experienced clinicians, clinician training in communication and symptom management, regular meetings of senior clinicians with families, bereavement programs, and end-of-life care quality monitoring. However, few of these strategies were widely available. CONCLUSIONS Intensive care unit directors perceive important barriers to optimal end-of-life care but also universally endorse many practical strategies for quality improvement.
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Affiliation(s)
- Judith E Nelson
- Department of Medicine, Hertzberg Palliative Care Institute, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Abstract
• Background Little research has been conducted to validate pain assessment tools in critical care, especially for patients who cannot communicate verbally.
• Objective To validate the Critical-Care Pain Observation Tool.
• Methods A total of 105 cardiac surgery patients in the intensive care unit, recruited in a cardiology health center in Quebec, Canada, participated in the study. Following surgery, 33 of the 105 were evaluated while unconscious and intubated and 99 while conscious and intubated; all 105 were evaluated after extubation. For each of the 3 testing periods, patients were evaluated by using the Critical-Care Pain Observation Tool at rest, during a nociceptive procedure (positioning), and 20 minutes after the procedure, for a total of 9 assessments. Each patient’s self-report of pain was obtained while the patient was conscious and intubated and after extubation.
• Results The reliability and validity of the Critical-Care Pain Observation Tool were acceptable. Interrater reliability was supported by moderate to high weighted κ coefficients. For criterion validity, significant associations were found between the patients’ self-reports of pain and the scores on the Critical-Care Pain Observation Tool. Discriminant validity was supported by higher scores during positioning (a nociceptive procedure) versus at rest.
• Conclusions The Critical-Care Pain Observation Tool showed that no matter their level of consciousness, critically ill adult patients react to a noxious stimulus by expressing different behaviors that may be associated with pain. Therefore, the tool could be used to assess the effect of various measures for the management of pain.
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Affiliation(s)
- Céline Gélinas
- School of Nursing, McGill University, Montreal, Quebec (cg), Faculty of Nursing, Laval University, Quebec City, Quebec (lf, cv, mf), and Department of Physiological Nursing, University of California, San Francisco, Calif (kp)
| | - Lise Fillion
- School of Nursing, McGill University, Montreal, Quebec (cg), Faculty of Nursing, Laval University, Quebec City, Quebec (lf, cv, mf), and Department of Physiological Nursing, University of California, San Francisco, Calif (kp)
| | - Kathleen A. Puntillo
- School of Nursing, McGill University, Montreal, Quebec (cg), Faculty of Nursing, Laval University, Quebec City, Quebec (lf, cv, mf), and Department of Physiological Nursing, University of California, San Francisco, Calif (kp)
| | - Chantal Viens
- School of Nursing, McGill University, Montreal, Quebec (cg), Faculty of Nursing, Laval University, Quebec City, Quebec (lf, cv, mf), and Department of Physiological Nursing, University of California, San Francisco, Calif (kp)
| | - Martine Fortier
- School of Nursing, McGill University, Montreal, Quebec (cg), Faculty of Nursing, Laval University, Quebec City, Quebec (lf, cv, mf), and Department of Physiological Nursing, University of California, San Francisco, Calif (kp)
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Gélinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care 2006; 15:420-7. [PMID: 16823021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Little research has been conducted to validate pain assessment tools in critical care, especially for patients who cannot communicate verbally. OBJECTIVE To validate the Critical-Care Pain Observation Tool. METHODS A total of 105 cardiac surgery patients in the intensive care unit, recruited in a cardiology health center in Quebec, Canada, participated in the study. Following surgery, 33 of the 105 were evaluated while unconscious and intubated and 99 while conscious and intubated; all 105 were evaluated after extubation. For each of the 3 testing periods, patients were evaluated by using the Critical-Care Pain Observation Tool at rest, during a nociceptive procedure (positioning), and 20 minutes after the procedure, for a total of 9 assessments. Each patient's self-report of pain was obtained while the patient was conscious and intubated and after extubation. RESULTS The reliability and validity of the Critical-Care Pain Observation Tool were acceptable. Interrater reliability was supported by moderate to high weighted kappa coefficients. For criterion validity, significant associations were found between the patients' self-reports of pain and the scores on the Critical-Care Pain Observation Tool. Discriminant validity was supported by higher scores during positioning (a nociceptive procedure) versus at rest. CONCLUSIONS The Critical-Care Pain Observation Tool showed that no matter their level of consciousness, critically ill adult patients react to a noxious stimulus by expressing different behaviors that may be associated with pain. Therefore, the tool could be used to assess the effect of various measures for the management of pain.
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Abstract
To compare the symptom experiences between men and women with acute coronary syndromes (ACS), we surveyed a convenience sample of 112 subjects with a final diagnosis of ACS in four hospitals. Our study found that after adjusting for cardiac diagnosis, diabetes, and age, women were more likely than men to experience chest discomfort rather than chest pain; pain/discomfort only in areas of the body other than the chest; pain/discomfort that started first either in the arm(s) or in areas of the body other than the chest; and unexplained anxiety. Women were less likely than men to experience chest pain/discomfort, pain/discomfort in the left side of the chest, and chest pain/discomfort as the most worrisome symptom. Significant gender differences were observed in the reports of several symptoms associated with ACS. This study is the first to identify different pain/discomfort referral patterns between men and women that require further validation.
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Affiliation(s)
- Wan Chen
- School of Nursing, University of California at San Francisco, San Francisco, California 94143, USA
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Abstract
Recognizing similarities and differences in symptom experiences of acute myocardial infarction (AMI) between men and women has implications for both health care providers and the general public. Rapid accurate diagnosis is necessary to implement timely lifesaving treatment. The purpose of this article is to critically review and evaluate studies that have compared symptoms of AMI between men and women. Research to date has demonstrated that during AMI, women are more likely than men to report shortness of breath, nausea, vomiting, back pain, jaw pain, neck pain, cough, and fatigue, but less likely than men to report chest pain and sweating. However, the findings were inconsistent across studies. These inconsistent findings could be attributable to methodological issues such as collecting data from medical records, small sample sizes, and controversial eligibility criteria for studies. More studies are needed to confirm gender differences in symptom experiences of AMI.
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Affiliation(s)
- Wan Chen
- School of Nursing, University of California at San Francisco, Box 0606, San Francisco, CA 94143, USA
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O’Leary-Kelley CM, Puntillo KA, Barr J, Stotts N, Douglas MK. Nutritional Adequacy in Patients Receiving Mechanical Ventilation Who Are Fed Enterally. Am J Crit Care 2005. [DOI: 10.4037/ajcc2005.14.3.222] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
• Background Inadequate nutritional intake in critically ill patients can lead to complications resulting in increased mortality and healthcare costs. Several factors limit adequate nutritional intake in intensive care unit patients given enteral feedings.
• Objective To examine the adequacy of enteral nutritional intake and the factors that affect its delivery in patients receiving mechanical ventilation.
• Methods A prospective, descriptive design was used to study 60 patients receiving enteral feedings at target or goal rate. Energy requirements were determined for the entire sample by using the Harris-Benedict equation; energy requirements for a subset of 25 patients were also determined by using indirect calorimetry. Energy received via enteral feeding and reason and duration of interruptions in feedings were recorded for 3 consecutive days.
• Results Mean estimated energy requirements (8996 kJ, SD 1326 kJ) and mean energy intake received (5899 kJ, SD 3058 kJ) differed significantly (95% CI 3297-3787; P < .001). A total of 41 patients (68.3%) received less than 90% of their required energy intake, 18 (30.0%) received within ±10%, and 1 (1.7%) received more than 110%. Episodes of diarrhea, emesis, large residual volumes, feeding tube replacements, and interruptions for procedures accounted for 70% of the variance in energy received (P<.001). Procedural interruptions alone accounted for 45% of the total variance. Estimated energy requirements determined via indirect calorimetry and mean energy received did not differ.
• Conclusions Most critically ill patients receiving mechanical ventilation who are fed enterally do not receive their energy requirements, primarily because of frequent interruptions in enteral feedings.
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Affiliation(s)
- Colleen M. O’Leary-Kelley
- Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif (CMO, JB, MKD), Department of Physiological Nursing, University of California, San Francisco, San Francisco, Calif (KAP, NS), and Stanford University School of Medicine, Stanford, Calif (JB)
| | - Kathleen A. Puntillo
- Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif (CMO, JB, MKD), Department of Physiological Nursing, University of California, San Francisco, San Francisco, Calif (KAP, NS), and Stanford University School of Medicine, Stanford, Calif (JB)
| | - Juliana Barr
- Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif (CMO, JB, MKD), Department of Physiological Nursing, University of California, San Francisco, San Francisco, Calif (KAP, NS), and Stanford University School of Medicine, Stanford, Calif (JB)
| | - Nancy Stotts
- Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif (CMO, JB, MKD), Department of Physiological Nursing, University of California, San Francisco, San Francisco, Calif (KAP, NS), and Stanford University School of Medicine, Stanford, Calif (JB)
| | - Marilyn K. Douglas
- Veterans Affairs Palo Alto Health Care System, Palo Alto, Calif (CMO, JB, MKD), Department of Physiological Nursing, University of California, San Francisco, San Francisco, Calif (KAP, NS), and Stanford University School of Medicine, Stanford, Calif (JB)
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O'Leary-Kelley CM, Puntillo KA, Barr J, Stotts N, Douglas MK. Nutritional adequacy in patients receiving mechanical ventilation who are fed enterally. Am J Crit Care 2005; 14:222-31. [PMID: 15840896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND Inadequate nutritional intake in critically ill patients can lead to complications resulting in increased mortality and healthcare costs. Several factors limit adequate nutritional intake in intensive care unit patients given enteral feedings. OBJECTIVE To examine the adequacy of enteral nutritional intake and the factors that affect its delivery in patients receiving mechanical ventilation. METHODS A prospective, descriptive design was used to study 60 patients receiving enteral feedings at target or goal rate. Energy requirements were determined for the entire sample by using the Harris-Benedict equation; energy requirements for a subset of 25 patients were also determined by using indirect calorimetry. Energy received via enteral feeding and reason and duration of interruptions in feedings were recorded for 3 consecutive days. RESULTS Mean estimated energy requirements (8996 kJ, SD 1326 kJ) and mean energy intake received (5899 kJ, SD 3058 kJ) differed significantly (95% CI 3297-3787; P < .001). A total of 41 patients (68.3%) received less than 90% of their required energy intake, 18 (30.0%) received within +/-10%, and 1 (1.7%) received more than 110%. Episodes of diarrhea, emesis, large residual volumes, feeding tube replacements, and interruptions for procedures accounted for 70% of the variance in energy received (P<.001). Procedural interruptions alone accounted for 45% of the total variance. Estimated energy requirements determined via indirect calorimetry and mean energy received did not differ. CONCLUSIONS Most critically ill patients receiving mechanical ventilation who are fed enterally do not receive their energy requirements, primarily because of frequent interruptions in enteral feedings.
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Chan G, Neighbor ML, LaBossiere LL, Puntillo KA. 26. Postdischarge Pain Intensity and Functional Status of Patients Who Presented to the Emergency Department in Pain. J Emerg Nurs 2004. [DOI: 10.1016/j.jen.2004.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
OBJECTIVE Patients frequently display behaviors during procedures that may be pain related. Clinicians often rely on the patient's demonstration of behaviors as a cue to presence of pain. The purpose of this study was to identify specific pain-related behaviors and factors that predict the degree of behavioral responses during the following procedures: turning, central venous catheter insertion, wound drain removal, wound care, tracheal suctioning, and femoral sheath removal. DESIGN Prospective, descriptive study. SETTING Multiple units in 169 hospitals in United States, Canada, England, and Australia. PATIENTS A total of 5,957 adult patients who underwent one of the six procedures. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A 30-item behavior observation tool was used to note patients' behaviors before and during a procedure. By comparing behaviors exhibited before and during the procedure as well as behaviors in those with and without procedural pain (as noted on a 0-10 numeric rating scale), we identified specific procedural pain behaviors: grimacing, rigidity, wincing, shutting of eyes, verbalization, moaning, and clenching of fists. On average, there were significantly more behaviors exhibited by patients with vs. without procedural pain (3.5 vs. 1.8 behaviors; t = 38.3, df = 5072.5; 95% confidence interval, 1.6-1.8). Patients with procedural pain were at least three times more likely to have increased behavioral responses than patients without procedural pain. A simultaneous regression model determined that 33% of the variance in amount of pain behaviors exhibited during a procedure was explained by three factors: degree of procedural pain intensity, degree of procedural distress, and undergoing the turning procedure. CONCLUSIONS Because of the strong relationship between procedural pain and behavioral responses, clinicians can use behavioral responses of verbal and nonverbal patients to plan for, implement, and evaluate analgesic interventions.
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Affiliation(s)
- Kathleen A Puntillo
- Critical Care/Trauma Graduate Nursing Program, University of California, San Francisco, CA, USA
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Abstract
The technology and expertise of critical care practice support patients through life-threatening illnesses. Most recover; some die quickly; others, however, linger--neither improving nor acutely dying, alive but with a dwindling capacity to recover from their injury or illness. Management of these patients is often dominated by the question: Is it appropriate to continue life-sustaining therapy? Patients rarely participate in these pivotal discussions because they are either too sick or too heavily sedated. As a result, the decision often falls to the family or the surrogate decision maker, in consultation with the medical team. Decisions of such import are emotionally stressful and are often a source of disagreement. Failure to resolve such disagreements may create conflict that compromises patient care, engenders guilt among family members, and creates dissatisfaction for health care professionals. However, the potential for strained communications is mitigated if clinicians provide timely clinical and prognostic information and support the patient and family with aggressive symptom control, a comfortable setting, and continuous psychosocial support. Effective communication includes sharing the burden of decision making with family members. This shift from individual responsibility to patient-focused consensus often permits the family to understand, perhaps reluctantly and with great sadness, that intensive caring may involve letting go of life-sustaining interventions.
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Affiliation(s)
- Thomas J Prendergast
- Departments of Medicine and Anesthesiology, Dartmouth-Hitchcock Medical Center, Section of Pulmonary and Critical Care Medicine (3D), 1 Medical Center Dr, Lebanon, NH 03756, USA.
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