Nurses' alarm fatigue, influencing factors, and its relationship with burnout in the critical care units: A cross-sectional study

BACKGROUND

Excessive number of alarms and false and nonactionable alarms may lead to alarm fatigue. Alarm fatigue could easily contribute to burnout. Burnout may reduce nurses' sensitivity to alarms, thus affecting patients' safety due to insufficient response to the alarms. However, no study has examined nurses' alarm fatigue in Ghana.

OBJECTIVES

The objective of this study was to investigate the level of alarm fatigue and its associated factors, as well as determine its relationship with burnout among nurses working in the critical care units of hospitals in Ghana.

METHODS

The cross-sectional study was conducted in critical care units of five hospitals in Ghana from November 2021 to January 2022. A total of 364 nurses were recruited and completed the questionnaire. Alarm fatigue was assessed by the alarm fatigue questionnaire, which was originally developed in Chinese and was translated into English using a standard protocol. Burnout was assessed using the Maslach Burnout Inventory.

RESULTS

The overall alarm fatigue score was 76.43 ± 27.80 out of 124. Longer years working at the critical care unit (B = -2.50, 95% confidence interval [CI]: -4.62, -0.37) and having policies related to alarm management (B = -10.77, 95% CI: -3.50, -18.04) were associated with a decreased risk of alarm fatigue, while working in neonatal intensive care unit (B = 16.35, 95% CI: 2.48, 30.21) and postanesthesia care unit (B = 15.16; 95% CI: 0.32, 30.01), and having anxiety and stress (B = 8.15, 95% CI: 1.30, 15.00) were associated with an increased risk of alarm fatigue. In addition, alarm fatigue was positively associated with emotional exhaustion (r = 0.52, P < 0.001) and depersonalisation (r = 0.43, P < 0.001) but not personal accomplishment (r = -0.09, P = 0.100).

CONCLUSION

Critical care nurses in Ghana experienced higher levels of alarm fatigue, which is affected by multiple factors. There is a significant link between nurses' alarm fatigue and burnout. Our findings provide important guidance for future intervention programs to improve critical care nurses' alarm fatigue by introducing policies on alarm management and improving nurses' psychological health, with a special focus on nurses with shorter working years and working in neonatal intensive care unit and postanesthesia care unit.

A Nationwide Survey on the Practice of End-of-life Care Issues in Critical Care Units in India

Background

End-of-life (EOL) care is the care of terminally ill patients who are nearing their end. It includes important components like palliative care, supportive care, hospice care, patient's right to choose, and choice of medical intervention, including continuation of routine medical interventions. The aim of this survey was to assess the practices of EOL care in various critical care units in India.

Methods

The participants included clinicians involved in EOL care of patients with advanced diseases in different hospital across India. We sent blast emails and posted links on social media for inviting participants to take the survey. Study data were collected and managed by using Google Forms. The collected information was automatically entered into a spread sheet and stored in a secure database.

Results

In total, 91 clinicians took the survey. The years of experience, practice area, and setting had significant effect on the palliative care, terminal strategy, and prognostication in terminally ill patients (p < 0.05). Statistical analysis was done using software STATA. Descriptive statistics were performed, and results were presented as number (percentage).

Conclusion

The years of work experience, the practice area, and the practice setting have a strong impact on EOL care management of terminally ill patients. There are a lot of gaps in providing EOL care for these patients. Many reforms are needed in the Indian health care system to make EOL care better.

How to cite this article

Kapoor I, Prabhakar H, Mahajan C, Zirpe KG, Tripathy S, Wanchoo J, et al. A Nationwide Survey on the Practice of End-of-life Care Issues in Critical Care Units in India. Indian J Crit Care Med 2023;27(5):305-314.

Cardiorespiratory coupling in mechanically ventilated patients studied via synchrogram analysis

Respiration and cardiac activity are strictly interconnected with reciprocal influences. They act as weakly coupled oscillators showing varying degrees of phase synchronization and their interactions are affected by mechanical ventilation. The study aims at differentiating the impact of three ventilatory modes on the cardiorespiratory phase coupling in critically ill patients. The coupling between respiration and heartbeat was studied through cardiorespiratory phase synchronization analysis carried out via synchrogram during pressure control ventilation (PCV), pressure support ventilation (PSV), and neurally adjusted ventilatory assist (NAVA) in critically ill patients. Twenty patients were studied under all the three ventilatory modes. Cardiorespiratory phase synchronization changed significantly across ventilatory modes. The highest synchronization degree was found during PCV session, while the lowest one with NAVA. The percentage of all epochs featuring synchronization regardless of the phase locking ratio was higher with PCV (median: 33.9%, first-third quartile: 21.3-39.3) than PSV (median: 15.7%; first-third quartile: 10.9-27.8) and NAVA (median: 3.7%; first-third quartile: 3.3-19.2). PCV induces a significant amount of cardiorespiratory phase synchronization in critically ill mechanically ventilated patients. Synchronization induced by patient-driven ventilatory modes was weaker, reaching the minimum with NAVA. Findings can be explained as a result of the more regular and powerful solicitation of the cardiorespiratory system induced by PCV. The degree of phase synchronization between cardiac and respiratory activities in mechanically ventilated humans depends on the ventilatory mode.

Association between in-ICU red blood cells transfusion and 1-year mortality in ICU survivors

BACKGROUND

Impact of in-ICU transfusion on long-term outcomes remains unknown. The purpose of this study was to assess in critical-care survivors the association between in-ICU red blood cells transfusion and 1-year mortality.

METHODS

FROG-ICU, a multicenter European study enrolling all-comers critical care patients was analyzed (n = 1551). Association between red blood cells transfusion administered in intensive care unit and 1-year mortality in critical care survivors was analyzed using an augmented inverse probability of treatment weighting-augmented inverse probability of censoring weighting method to control confounders.

RESULTS

Among the 1551 ICU-survivors, 42% received at least one unit of red blood cells while in intensive care unit. Patients in the transfusion group had greater severity scores than those in the no-transfusion group. According to unweighted analysis, 1-year post-critical care mortality was greater in the transfusion group compared to the no-transfusion group (hazard ratio (HR) 1.78, 95% CI 1.45-2.16). Weighted analyses including 40 confounders, showed that transfusion remained associated with a higher risk of long-term mortality (HR 1.21, 95% CI 1.06-1.46).

CONCLUSIONS

Our results suggest a high incidence of in-ICU RBC transfusion and that in-ICU transfusion is associated with a higher 1-year mortality among in-ICU survivors. Trial registration ( NCT01367093 ; Registered 6 June 2011).

Nurses' knowledge about palliative care in a critical care unit

INTRODUCTION AND OBJECTIVE

Patients admitted to the Critical Care Unit (CCU) have a high mortality rate due to their complexity. Palliative care (PC) is a key aspect that can improve patient care. Because of the essential role of the nurse in providing this care, training, and including it in daily practice are needed. Our objective was to review the level of knowledge among the nurses in the CCU regarding PC and assess whether there is an association between each of the study variables.

METHODOLOGY

We performed a descriptive observational cross-sectional study in the CCU of a tertiary level university hospital. The questionnaire Palliative Care Quiz for Nurses, previously validated and translated into Spanish, was used. This is a self-administered questionnaire consisting of 20 multiple-choice questions (True/False/Do not know-Do not answer) which evaluates three aspects of PC: philosophy, psychosocial and control of pain and other symptoms. In addition, sociodemographic data was collected. Descriptive and inferential statistics were used, a p < .05 was considered statistically significant in all cases.

RESULTS

The questionnaire was administered to 68 nursers, with an average age of 34.98 ± 12.12 years, and 13.00 ± 11.75 years of professional experience. Twelve nurses have Master studies and 28 nurses have received training in PC. The percent of correct answers of the questionnaire was 56.98%. There were no statistically significant differences between the total average score and the variables studied. However, looking at each aspect on the scale, an association was found between PC training and control of pain and other symptoms (p = .033).

CONCLUSION

Critical care nurses have a basic knowledge of PC, it being insufficient in the psychological sphere. Developing a training programme which identifies misconceptions and training deficits might improve the management of symptom control in palliative care patients, quality of care and its application.

Factors Associated with ICU Mortality at Hawassa University Comprehensive Specialized Hospital (HUCSH)

BACKGROUND

Providing acute care to critically ill patients in intensive care unit (ICU) is a global necessity, regardless of health system capacity. The objectives of the present study were to assess the reasons for admission and clinical outcomes of adult patients admitted to general ICU at Hawassa University Comprehensive Specialized Hospital (HUCSH).

METHODS

A retrospective study based on a record review of logbook and charts of 310 adult patients admitted to general ICU of HUCSH between April 2012 and April 2017. Both descriptive analysis and inferential statistics were used.

RESULTS

The average age was 41 ± 17.9 years (range: 18-100 years). Males accounted 51.6%. The average duration of stay in the ICU was 5.3 ± 6.7 days (range 1-49 days). Cardiovascular disorders were the commonest cause of admission, accounted for 22.9%, followed by neurological disorders (17.7%), and trauma related illnesses (13.9%). Among 310 adults admitted during the study period, 23.1% required mechanical ventilator support; and 5.3% developed Hospital acquired infection. In-patient mortality rate was 45.8%. In multivariate analysis, the presences of aspiration pneumonia, and need for ventilator support, acute kidney injury, hospital acquired infection, and short ICU stays were associated with ICU mortality.

CONCLUSION

The present study indicates high prevalence of ICU mortality among adults admitted to HUCSH during the study period. ICU mortality was associated with the presences of renal failure, hospital acquired infections, aspiration pneumonia and the need for mechanical ventilator.

Evaluation of a digital system to predict unplanned admissions to the intensive care unit: A mixed-methods approach

Background

We have developed the Hospital Alerting Via Electronic Noticeboard (HAVEN) which aims to identify hospitalised patients most at risk of reversible deterioration. HAVEN combines patients’ vital-sign measurements with laboratory results, demographics and comorbidities using a machine learnt algorithm.

Objectives

The aim of this study was to identify variables or concepts that could improve HAVEN predictive performance.

Methods

This was an embedded, mixed methods study. Eligible patients with the five highest HAVEN scores in the hospital (i.e., ‘HAVEN Top 5′) had their medical identification details recorded. We conducted a structured medical note review on these patients 48 hours post their identifiers being recorded. Methods of constant comparison were used during data collection and to analyse patient data.

Results

The 129 patients not admitted to ICU then underwent constant comparison review, which produced three main groups. Group 1 were patients referred to specialist services (n = 37). Group 2 responded to ward-based treatment, (n = 38). Group 3 were frail and had documented treatment limitations (n = 47).

Conclusions

Digital-only validation methods code the cohort not admitted to ICU as ‘falsely positive’ in sensitivity analyses however this approach limits the evaluation of model performance. Our study suggested that coding for patients referred to other specialist teams, those with treatment limitations in place, along with those who are deteriorating but then respond to ward-based therapies, would give a more accurate measure of the value of the scores, especially in relation to cost-effectiveness of resource utilisation.

Stress Level and Its Determinants among Staff (Doctors and Nurses) Working in the Critical Care Unit

Background: Very few extensive studies regarding job stressors among doctors and nurses have been conducted in India. It is important to explore the workplace to understand various stressors that adversely affect the well-being of an individual and also affect health care and needs of patients and relatives. Considering this, the present study was planned to determine stress among doctors and nurses from the critical care unit (CCU) and to find the association of stress with selected variables.

Materials and methods: This observational cross-sectional study was conducted among all staff (doctors and nurses) from the CCU. Data were collected with a pilot-tested, predesigned, validated questionnaire using the Google survey tool consisting of sociodemographic details and the ICMR work stress questionnaire. Analysis of data was done with SPSS version 25.

Results: Of 105 participants, 57 (54.3%) were doctors and 48 (45.7%) were nurses. A total of 48.6% (51) of participants scored 32 of 64, that is, managed stress very well, and 51.4% of participants (54) scored 65 of 95, that is, having a reasonably safe level of stress, but certain areas need improvement.

Conclusion: Stress was significantly more among females and those who have sleep problems. No statistically significant difference was found between the level of stress and age, relationship with seniors, exercise, and comorbidities.

How to cite this article: Patil VC, Patil SV, Shah JN, Iyer SS. Stress Level and Its Determinants among Staff (Doctors and Nurses) Working in the Critical Care Unit. Indian J Crit Care Med 2021;25(8):886–889.

Spleno-aortic radiodensity ratio - A distinctive imaging feature to predict short-term outcome in critical care unit

INTRODUCTION

To investigate the value of contrast-enhanced CT findings - splenic and aortic radiodensities and their ratios (spleno-aortic ratio) - in predicting the prognosis of critical care unit patients (CCU).

METHODS

One hundred thirteen continuous CCU patients with an acute deterioration (Group A: 37 women, age: 67.2 ± 14.0 years) were included in the retrospective study. Radiodensities of the spleen and aorta were evaluated by two radiologists separately. The spleno-aortic ratio was calculated. Matthews correlation coefficient (MCC) was used in conjunction with receiver operating characteristic analysis (ROC) to assess if and which parameter was most suitable for short-term mortality prediction. The intra-class correlation coefficient assessed consensus across readers. To validate the results for the best predictor, a second cohort was evaluated (Group B: 354 CT scans).

RESULTS

The portal venous spleno-aortic ratio was best suited to predict 72-hour mortality (AUC = 0.91). A threshold ratio ≤0.53 predicted short-term mortality with a high sensitivity (80.95%) and specificity (96.74%, MCC = 0.79). The post-test probability was 85%, assuming a pre-test probability of 18.6% (72-hour mortality rate). ICCs of HU measurements in the aorta, spleen, and its ratios showed high interrater agreement (ICC: 0.92-0.99). In a control cohort, a threshold ratio ≤0.53 predicted CCU patientś outcome satisfactorily (SENS = 83.93%, SPEC = 97.65%, PPV = 87.00%, NPV = 97.00%).

CONCLUSIONS

The portal venous spleno-aortic ratio serves as a distinctive imaging feature to predict short-term mortality. For CCU patients with a cut-off portal venous spleno-aortic ratio ≤0.53, the risk of dying within three days after CT scan is approximately twenty times higher.

Postoperative Admission in Critical Care Units Following Gynecologic Oncology Surgery: Outcomes Based on a Systematic Review and Authors' Recommendations

BACKGROUND/AIM

The present study aimed to evaluate the predictors of admission to the Critical Care Units (CCUs) and factors predisposing to prolonged stay in CCUs after gynecological oncology surgery.

PATIENTS AND METHODS

Studies which addressed cases of women who underwent surgery for gynecological malignancies and required postoperative CCU admission were included.

RESULTS

Seven studies with 3820 patients were included. Among them, 1680 required admission to CCU. Advanced age, higher Charlson Comorbidity Index (CCI) score, longer operative times, protracted blood loss and intestinal resection were associated with higher probability of CCU admission. Patients' age, operative times, blood loos and intestinal resection were significant predictors of prolonged stay to CCUs.

CONCLUSION

Admission to CCU and length of stay following surgery for gynecologic malignancies is driven by specific patient characteristics as well as intraoperative values. Further studies are needed to validate high risk patients who will benefit from postoperative care to CCUs to ensure favorable postoperative outcomes and cost-effectiveness.

Needs of family members of patients admitted to a university hospital critical care unit, Izmir Turkey: comparison of nurse and family perceptions

Purpose:

This study aims to compare the perceptions of nurses and families on the needs of the relatives of the patients in Intensive Care Unit (ICU).

Methods

This cross-sectional study was conducted in the ICU of a university hospital. The study comprised 213 critical care patients’ relatives and 54 nurses working in the same ICU. Data were collected using the Turkish version of Critical Care Family Needs Inventory (CCFNI) and a questionnaire on the characteristics of the participants. The difference between the perceptions of families and nurses was analyzed using Student t-test. Results: CCFNI’s assurance/proximity subscale mean scores ranked first among bothpatients and nurses. The item “To be assured the best care possible is being given to the patient” was the top priority for both groups. Mean assurance/proximity and information dimensions of relatives were significantly higher compared to nurses (p < 0.001). No significant difference was found between the perception of patient relatives and nurses related to support and comfort dimensions (p < 0.05).

Conclusion

The needs of the relatives of patients are underestimated by nurses. This inhibited the performance of ICU nurses in line with the holistic care approach. Educational objectives that include the needs of ICU patients’ relatives should be incorporated into the undergraduate and in-service training of nurses. Policies should be established to create space and time for effective relative-nurse communication.

Patient and nurse content preferences for a communication board to facilitate dialogue in the intensive care unit

OBJECTIVES

The main aim of this study was to identify patient and nurse content preferences for a communication board to facilitate effective communication (dialogue) in the critical care unit.

RESEARCH DESIGN

A qualitative research design focusing on explorative and descriptive components was used to address the aim of the research study. The study employed two participant groups. Semi-structured interviews and focus group discussions were conducted with critically ill patients (N = 10) and critical care nurses (N = 30).

SETTING

The study was conducted in four different private hospitals of the same hospital group in Gauteng, South Africa.

FINDINGS

Four distinct themes were identified in the research regarding the vocabulary items that participants would like to have included.

CONCLUSION

The findings suggest that patients perceive a communication board to be valuable in enhancing communication in the critical care unit; that cultural and linguistic diversity should be considered; and that patients and nurses have varying opinions on topics of priority during communication.

Hospitalization-related economic impact of patients with cardiogenic shock in a high-complexity reference centre

AIMS 

Cardiogenic shock (CS) is associated with high mortality. Current guidelines strongly recommend centralizing the care of these patients in high-complexity centres. We described the hospitalization-related economic cost and its main determinants in patients with CS in a high-complexity reference centre.

METHODS AND RESULTS 

This is a single-centre, retrospective study. All patients with CS (2015-17) were included. Hospitalization-related cost per patient was calculated by analytical accountability method, including hospital stay-related expenditures, interventions, and consumption of devices. Expenditure was expressed in 2018 euros. All-cause mortality during follow-up was registered. Ratio of cost per life-year gained (LYG) was also calculated. A total of 230 patients were included, with mean age of 63 years. In-hospital mortality was 88/230 (38.3%). Hospital stay was longer in patients surviving after the admission (21.7 vs. 7.5 days, P < 0.001). Total economic cost for the overall cohort was 3 947 118€ (mean/patient 17 161€). Most of this cost was attributable to hospital stay (81.1%). The rest of the expenditure was due to in-hospital procedures (13.1%) and the use of devices (5.8%). Most of hospital stay-related costs (79.8%) were due to Critical Care Unit stay. Mean follow-up was 651 days. Total LYG was 409.77 years for the whole series. The observed ratio of cost per LYG was 9632.52 €/LYG.

CONCLUSIONS 

Management of CS in a reference centre is associated to a significant economic cost, but with a low ratio of cost per LYG. Most of this cost is attributable to hospital stay, specifically in critical care units.

COVID-19: Biosafety in the Intensive Care Unit

Purpose of Review

COVID-19 is a new, highly transmissible disease to which healthcare workers (HCWs) are exposed, especially in the intensive care unit (ICU). Information related to protection mechanisms is heterogeneous, and the infected HCWs’ number is increasing. This review intends to summarize the current knowledge and practices to protect ICU personnel during the patient management process in the context of the current pandemic.

Recent Findings

The transmission mechanisms of SARS-CoV-2 are mainly respiratory droplets, aerosols, and contact. The virus can last for a few hours suspended in the air and be viable on surfaces for several days. Some procedures carried out in the ICU can generate aerosols. The shortage of respirators, such as the N95, has generated an increase in the demand for other protective equipment in critical care settings.

Summary

The probability of transmission depends on the characteristics of the pathogen, the availability of quality personal protective equipment, and the human factors associated with the performance of health workers. It is necessary to have knowledge of the virus and availability of the best possible personal protection equipment, develop skills for handling equipment, and develop non-technical skills during all intensive care process; this can be achieved through structured training.

Knowledge and Awareness of End-of-life Care among Doctors Working in Intensive Care Units at a Tertiary Care Center: A Questionnaire-based Study

INTRODUCTION

End-of-life care (EOLC) is an increasingly important concern in the management of terminally ill patients. Effective EOLC depends significantly on the physicians working in the critical care units. Thus, adequate knowledge of critical care professionals regarding EOLC is important. We conducted this study to evaluate the awareness and knowledge of doctors working in critical care units toward EOLC.

MATERIALS AND METHODS

Doctors working in critical care units were invited to fill paper-based questionnaire. The validated questionnaire was constructed based on the existing literature on EOLC and expert opinion. The questionnaire comprised four sections: demographic details, experience with EOLC situations, general awareness of EOLC, and specific awareness of EOLC in clinical practice. The collected data were analyzed by descriptive analysis.

RESULTS

Most respondents had not counseled more than five families regarding EOLC over 1 month. Majority of the respondents (81.7%) had heard of EOLC; the major source of information being their work in the concerned specialty. Only 29.2% of the respondents applied EOLC principles in their clinical practice. Main barriers were lack of information and training. Only 20.3% of the respondents were aware of Indian guidelines about EOLC. Majority of the respondents disagree regarding the usage of critical care units and resuscitation of terminally ill patients and were in favor of home care. One-third respondents felt uncomfortable in discussing EOLC issues with the families. Half of the respondents felt that they were only somewhat competent in managing EOLC issues. Most respondents opined that training and education in medical curriculum for terminally ill patients are lacking and were in strong favor of inclusion of specific training for the same.

CONCLUSION

The EOLC needs to be an integral part of critical care management and teaching curriculum. An integral referral system may also be an option for various advance disease patients getting treatment from critical care specialists for EOLC decision.

HOW TO CITE THIS ARTICLE

Agrawal K, Garg R, Bhatnagar S. Knowledge and Awareness of End-of-life Care among Doctors Working in Intensive Care Units at a Tertiary Care Center: A Questionnaire-based Study. Indian J Crit Care Med 2019;23(12):568-573.

Development of a tool to assess oral health-related quality of life in patients hospitalised in critical care

AIMS AND OBJECTIVES

Oral health deteriorates following hospitalisation in critical care units (CCU) but there are no validated measures to assess effects on oral health-related quality of life (OHQoL). The objectives of this study were (i) to develop a tool (CCU-OHQoL) to assess OHQoL amongst patients admitted to CCU, (ii) to collect data to analyse the validity, reliability and acceptability of the CCU-OHQoL tool and (iii) to investigate patient-reported outcome measures of OHQoL in patients hospitalised in a CCU.

METHODS

The project included three phases: (1) the development of an initial questionnaire informed by a literature review and expert panel, (2) testing of the tool in CCU (n = 18) followed by semi-structured interviews to assess acceptability, face and content validity and (3) final tool modification and testing of CCU-OHQoL questionnaire to assess validity and reliability.

RESULTS

The CCU-OHQoL showed good face and content validity and was quick to administer. Cronbach's alpha was 0.72 suggesting good internal consistency. For construct validity, the CCU-OHQoL was strongly and significantly correlated (correlation coefficients 0.71, 0.62 and 0.77, p < 0.01) with global OHQoL items. In the validation study, 37.8% of the participants reported a deterioration in self-reported oral health after CCU admission. Finally, 26.9% and 31% of the participants reported considerable negative impacts of oral health in their life overall and quality of life, respectively.

CONCLUSIONS

The new CCU-OHQoL tool may be of use in the assessment of oral health-related quality of life in CCU patients. Deterioration of OHQoL seems to be common in CCU patients.

Standards for Neurologic Critical Care Units: A Statement for Healthcare Professionals from The Neurocritical Care Society

Neurocritical care is a distinct subspecialty focusing on the optimal management of acutely ill patients with life-threatening neurologic and neurosurgical disease or with life-threatening neurologic manifestations of systemic disease. Care by expert healthcare providers to optimize neurologic recovery is necessary. Given the lack of an organizational framework and criteria for the development and maintenance of neurological critical care units (NCCUs), this document is put forth by the Neurocritical Care Society (NCS). Recommended organizational structure, personnel and processes necessary to develop a successful neurocritical care program are outlined. Methods: Under the direction of NCS Executive Leadership, a multidisciplinary writing group of NCS members was formed. After an iterative process, a framework was proposed and approved by members of the writing group. A draft was then written, which was reviewed by the NCS Quality Committee and NCS Guidelines Committee, members at large, and posted for public comment. Feedback was formally collated, reviewed and incorporated into the final document which was subsequently approved by the NCS Board of Directors.

Occupational stress and its related demographic factors among Iranian CCU nurses: a cross-sectional study

Objectives

Occupational stress can have an adverse effect on mental and physical health and performance of nurses. The aim of this study was to investigate the occupational stress of Iranian critical care unit (CCU) nurses and its related demographic factors.

Results

In this cross-sectional study, 155 CCU nurses were randomly selected. The Osipow Occupational Stress Questionnaire was used as data collection tool. The mean of nurses’ occupational stress was 210.13 ± 40.87 out of 300, which was at the “moderate-to-high” level. The highest mean of occupational stress was related to the subscale of “Role Overload” (36.30 ± 6.98) and the lowest mean was related to the subscale of “Physical Environment” (33.58 ± 9.76). There was no statistically significant difference between the mean occupational stress and variables of sex, age, academic degree and working experience.

Nurse-Physician Collaboration and the Professional Autonomy of Intensive Care Units Nurses

Background and aims

Poor collaboration between the physicians and the nurses may interfere with nursing performance in patient care. This study aimed to determine the nurse–physician collaboration and professional autonomy of intensive care nurses.

Subjects and methods

This descriptive correlational study was performed on 126 nurses working in the intensive care units (ICUs) of Ardabil, Iran. The data were collected using the Jefferson scale of attitudes toward physician–nurse collaboration’ (JSAPNC) and the Dempster Practice Behavior Scale (DPBS). The results were analyzed using descriptive statistics (mean, standard deviation, and frequency) and inferential statistics (t-test, ANOVA, and Pearson).

Results

The mean score of the nurse–physician collaboration was found to be 47.83 ± 3.9, which indicates good collaboration between physicians and nurses in the ICUs. The results showed that 73% of the nurses reported a moderate autonomy and 27% of them considered their autonomy to be high. There was no significant relationship between the nurse–physician collaboration and the professional autonomy of the nurses (p >0.05).

Conclusion

The nurses who participated in this study had a positive attitude toward collaboration with the physicians and a moderate level of professional autonomy. Interventions may be required to further enhance the level of nurse–physician collaboration and the professional autonomy of nurses.

How to cite this article

Aghamohammadi D, Dadkhah B, et al. Nurse-Physician Collaboration and the Professional Autonomy of Intensive Care Units Nurses. Indian J Crit Care Med 2019;23(4):178-181.

Prophylactic use of dressings for pressure ulcer prevention in the critical care unit

Multiple comorbidities and intensive therapy increase the risk of pressure ulcer (PU) development in critical care unit (CCU) patients. Given the high number of risk factors that CCU patients present with, it is important to acknowledge that not all PUs are entirely preventable, and incidence is thought to be between 14% and 42%. The consequences of acquiring a PU in critical care include increased mortality, morbidity and longer length of stay. Implementing prevention strategies as soon as the patient enters the unit can significantly reduce incidence. By adopting a proactive versus reactive mind-set, one CCU abandoned traditional PU risk assessment and implemented a number of intensive interventions, including the use of a prophylactic sacral dressing as an adjunct. As a result, PU incidence fell from 19.9 per 1000 patient population to 0.84 per 1000 patient population in 2014. In addition, 310 PU-free days were achieved.

Emergency ultrasound and echocardiography in patients with infarct-related cardiogenic shock : A survey among members of the German Society of Medical Intensive Care and Emergency Medicine

Current international and national guidelines promote the use of emergency echocardiography in patients with cardiogenic shock. We assessed whether these recommendations are followed in clinical practice of infarct-related cardiogenic shock patients. For this purpose we conducted a web-based survey among all members of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN); 40% of the DGIIN members completed the survey. Participants reported that in their department emergency echocardiography/ultrasound is performed on most patients in infarct-related cardiogenic shock presenting to the emergency department/chest pain unit or intensive care unit (58.6% versus 81.4%). Only 33% stated that on patients admitted directly to the catheterization laboratory emergency ultrasound/echocardiography is applied in their institution. Local availability of a standardized algorithm was lacking in the majority of departments (77.2%). A great proportion (38.3%) of participants stated that they personally had no formal training in emergency ultrasound. In order to meet the demands of the current guidelines, in addition to integration of ultrasound examinations into diagnostic algorithms, a structured training of all emergency and intensive care physicians is necessary.

Assessment of nurses interventions in the Management of Clinical Alarms in the critical care unit, Kenyatta National Hospital, a cross sectional study

BACKGROUND

Alarms in the critical areas are an important component of most of the machines as they alert nurses on the change in the patients' condition. Most patients in the critical care units cannot speak for themselves hence cannot pinpoint when their condition changes. It is therefore important to assess the nurses' interventions when managing clinical alarms. The purpose of this study was to assess interventions employed by nurses in the management of clinical alarms in the care of patients in the Critical Care Unit (CCU), Kenyatta National Hospital (KNH).

METHODS

A descriptive cross sectional study was carried out in the month of June 2014 where 87 nurses were recruited as study respondents. KNH/ University of Nairobi (UoN) Ethics and Research committee approved the research. A structured self administered questionnaire was used to collect data. The questionnaire contained some questions in a Likert scale in relation to the actions the nurses would take in the management of clinical alarms and some on whether policies on alarm management existed in the hospital, if they filled alarm checklists and how often and the types of alarms they would respond to first.

RESULTS

The respondents' responses were scored and from the results it was clear that there were some gaps in the management of clinical alarms. Majority of the nurses reported that they respond to alarms of all durations and do not fill alarm checklists as neither alarm checklists nor protocols are provided. From the findings there was a statistically significant association (p = 0.06) between age and whether the respondents assessed the cause of the alarm beep.

DISCUSSION

Respondents in this study respond to alarms of all durations in contrast to other studies where the findings indicate that nurses respond to alarms for different reasons, not just that the alarm sounds. Majority of the respondents scored averagely on the questions on whether they carry out most of the interventions or actions. This is inline with previous studies which have shown that healthcare personnel respond to alarms depending on the patient's physiological status.

CONCLUSIONS

Nurses in the unit carry out the standard nursing interventions on clinical alarms and, respond to alarms of all durations and do not fill alarm checklists. Alarm protocols should therefore be developed in the hospital, the nurses should be trained on management of clinical alarms and more nurses employed.

Nurses' perceptions of reasons for persistent low rates in hand hygiene compliance

AIM

The purpose of this study was to explore nurses' perceptions of reasons for persistent low rates in hand hygiene compliance in the Critical Care Unit and their recommendations for improvement.

DESIGN AND METHODS

This study used an exploratory, descriptive survey design to identify critical care nurses' perceptions of barriers to hand hygiene compliance in the unit and their recommendations for improvement.

RESULTS

Nurses selected high workload, understaffing and suggested lack of time as the main problems with hand hygiene compliance in the critical care unit. Second to that, they identified difficulty accessing sinks and lack of appropriately located hand sanitisers at the point of care complemented by suggestions of not enough sinks and inconveniently located hand sanitiser as major barriers to hand hygiene compliance.

CONCLUSION

Results of this study indicate that high workload and understaffing added to difficulty accessing hand hygiene resources contribute to low rates of hand hygiene compliance in the critical care unit. Addressing nursing understaffing and workload and making some environmental modifications to allow easy access to sinks and hand sanitisers may facilitate nurses hand hygiene compliance in this setting. Further studies on the relationship between nurses' workload, unit staffing, and hand hygiene compliance rates are needed.

Effects of technology on nursing care and caring attributes of a sample of Iranian critical care nurses

PURPOSE

To examine the association between attitudes of critical care nurses about influences of technology and their caring attributes.

STUDY DESIGN AND METHODOLOGY

In a cross-sectional study, firstly the psychometric properties of caring attributes questionnaire, which was developed to examine caring attributes of a sample of international nurses, was refined in a sample of 200 critical care nurses working in educational hospitals of a city in the southwest of Iran. Results of factor analysis with Varimax rotation decreased 60 items of caring attributes to 47 items which loaded under five subscales of caring negation, caring compassionate, caring advocacy, caring essence and caring communication. Secondly, attitudes of these nurses toward influences of technology on nursing care were assessed using a 22-item questionnaire, developed by the study researchers. Finally, the association between scores of caring attributes and attitudes toward influences of technology of this sample was determined.

RESULTS

There was a positive association between caring attributes and influences of technology among our study nurses. Caring attributes scores were higher in female single nurses. Although caring attributes' scores had decreased along with age and work experience, caring commitment was higher in older more experienced nurses. Furthermore, female nurses had a better attitude toward influences of technology on their care. In contrast, younger and less experienced nurses had negative views on the effects of technology on nursing care.

CONCLUSION

Continuing education and life-long learning on application of new technological equipment in nursing care and harmonising their use with caring values are necessary for nursing students and registered nurses to ensure delivering a patient-centred care, in a technologically driven environment.

Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: Four case scenarios

BACKGROUND

Failure to identify and respond to clinical deterioration is an important measure of patient safety, hospital performance and quality of care. Although studies have identified the role of patient, system and human factors in failure to rescue events, the role of 'inattentional blindness' as a possible contributing factor has been overlooked.

OBJECTIVES

To explore the nature and possible patient safety implications of inattentional blindness in critical care, emergency and perioperative nursing contexts.

METHODS

Analysis of four case scenarios drawn from a naturalistic inquiry investigating how nurses identify and manage gaps (discontinuities) in care. Data were collected via in-depth interviews from a purposeful sample of 71 nurses, of which 20 were critical care nurses, 19 were emergency nurses and 16 were perioperative nurses. Case scenarios were identified, selected and analysed using inattentional blindness as an interpretive frame.

RESULTS

The four case scenarios presented here suggest that failures to recognise and act upon patient observations suggestive of clinical deterioration could be explained by inattentional blindness. In all but one of the cases reported, vital signs were measured and recorded on a regular basis. However, teams of nurses and doctors failed to 'see' the early signs of clinical deterioration. The high-stress, high-complexity nature of the clinical settings in which these cases occurred coupled with high cognitive workload, noise and frequent interruptions create the conditions for inattentional blindness.

CONCLUSIONS

The case scenarios considered in this report raise the possibility that inattentional blindness is a salient but overlooked human factor in failure to rescue events across the critical care spectrum. Further comparative cross-disciplinary research is warranted to enable a better understanding of the nature and possible patient safety implications of inattentional blindness in critical care nursing contexts.

Optimising non-invasive mechanical ventilation: Which unit should care for these patients? A cohort study

BACKGROUND

Use of noninvasive ventilation (NIV) has extended beyond intensive care units (ICUs), becoming usual practice in emergency departments (EDs) and general wards.

OBJECTIVE

To analyse the relationship between nursing care and NIV outcome in different hospital units.

DESIGN AND SETTINGS

Three university hospitals and one community hospital participated in a prospective observational cohort study.

PARTICIPANTS

Ten units participated: 4 ICUs (1 surgical, 3 medical-surgical), 3 recovery (1 postsurgical, 2 EDs, 3 general wards).

METHOD

Treatment success/failure, interface intolerance and complications were evaluated according to patient characteristics, nursing care provided, and procedures used. Complications analysed included bronchoaspiration, pneumothorax, skin lesions, inability to manage secretions, eye irritations, deteriorating level of consciousness, gastric distension, and excessive air losses around the mask.

RESULTS

Of 387 patients, 194 (50.1%) were treated in ICU, 121 (31.3%) in ED, 38 (9.8%) postsurgery, and 34 (8.8%) in general wards. Regression analysis, adjusted for APACHE score and NIV indication, showed 3.3 times greater risk of NIV failure (95% CI [1.2-9.2]) in a university-hospital ICU with <50 NIV cases/year, compared to a community hospital ICU. In ICUs and general wards, NIV was suspended in 12% of patients due to interface intolerance. Acute-on-chronic lung diseases (ACLD) had lower risk of NIV failure (OR 0.2 [95% CI 0.06-0.69]) and lack of humidification was not associated with treatment failure (OR 0.2 [95% CI 0.1-0.4]). Poor secretion management was linked to pneumonia (OR 2.5 [95% CI 1.1-5.9]) and early weaning/extubation (OR 3.3 [95% CI 1.2-8.9]). Interface intolerance was associated with conventional ICU ventilators (OR 4.4 [95% CI 2.1-9.2]) and nasal skin lesions with excessive air losses (OR 2.4 [95% CI 1.1-5.3]), especially with oronasal masks (OR 3.5 [95% CI 1.1-11.3]).

CONCLUSIONS

Acute respiratory failure patients with pneumonia admitted to general wards had increased interface intolerance and NIV failure. Rotating mask types could improve NIV success in any unit administering this therapy.

Effect of White Noise on Sleep in Patients Admitted to a Coronary Care

Introduction: Sleep disorders are a common problem in patients in the critical care unit. The objective of the present study was to determine the effect of white noise on the quality of sleep in patients admitted to the CCU.

Methods: The present study was single-blind, quasi-experimental study. A total of 60 patients were selected using the purposive sampling method. Quality of sleep was measured with PSQI on the first day in admission, then after three nights of admission without any intervention for control group and for the experimental group quality of sleep measured by white noise with intensity of 50-60 dB then Quality of sleep was measured with PSQI. Data were analyzed by SPSS 13 software.

Results: The average total sleep time in the control group before the study reached from 7.08 (0.8) to 4.75 (0.66) hours after three nights of hospitalization, while in the experimental group, no significant changes were seen in the average sleep hours (6.69 ± 0.84 vs. 6.92 ± 0.89, P = 0.15).The average minutes of sleep in the control group before the study reached from 12.66 (7.51) to 25.83 (11.75) minutes after a three- night stay, while in the experimental group, no significant changes were observed in the average sleep duration (12.16 ± 7.50 vs. 11 ±6. 07, P = 0.16).

Conclusion: The use of white noise is recommended as a method for masking environmental noises, improving sleep, and maintaining sleep in the coronary care unit.

Clinical factors associated with inappropriate prophylaxis of venous thromboembolic disease in critically ill patients. A single day cross-sectional study

PURPOSE

A poor implementation of VTE prophylactic measures recommended for critically ill patients has been observed in several epidemiological studies. The clinical factors associated with this have not been clearly established. The objective of our study was to identify which factors could be related to the inappropriate use of VTE prophylaxis.

METHODS

Analytic epidemiological study based on different aspects of VTE prophylaxis performed on Spanish ICU patients. A multiple logistic regression analysis was conducted to identify the risk factors associated with inappropriate prophylaxis, according to the American College of Chest Physicians 2012 guidelines.

RESULTS

We enrolled 777 patients. On admission, 62% presented medical, 30% surgical and 8% major trauma pathology. Of all patients, 41% were receiving an inappropriate prophylaxis, including 19% which did not receive any prophylaxis. The presence of a contraindication for pharmacological prophylaxis (OR 3.91, 95% CI 2.50-6.10) and non-medical pathology at ICU admission (OR 11.09; 95% CI 7.63-16.12) were associated with inappropriate prophylaxis. In contrast, mechanical ventilation (OR 0.70, 95% CI 0.45-0.98), bed rest>48h (OR 0.61, 95% CI 0.49-0.98), the use of a protocol for VTE prophylaxis (OR 0.66, 95% CI 0.45-0.98) and a VTE risk scoring system (OR 0.49, 95% CI 0.24-0.98) were associated with adequate prophylaxis.

CONCLUSIONS

Our study highlighted a poor compliance with the VTE prophylaxis recommendations proposed for critical patients. The implementation of specific protocols for prophylaxis that include a correct evaluation according to VTE and haemorrhage risk, would allow for optimisation of mechanical and combined prophylaxis, improving adherence to the clinical practice guidelines.

Impact of erythropoietin on intensive care unit patients

Anemia is common in intensive care unit (ICU) patients. Red blood cell (RBC) transfusions are mainstays of their treatment and can be life-saving. Allogeneic blood components inherently bear risks of infection and immune reactions. Although these risks are rare in developed countries, recombinant human erythropoietin (rhEpo) and other erythropoiesis-stimulating agents (ESAs) have been considered alternative anti-anemia treatment options. As summarized herein, however, most of the clinical studies suggest that ESAs are not usually advisable in ICU patients unless approved indications exist (e.g., renal disease). First, ESAs act in a delayed way, inducing an increase in reticulocytes only after a lag of 3-4 days. Second, many critically ill patients present with ESA resistance as inflammatory mediators impair erythropoietic cell proliferation and iron availability. Third, the ESA doses used for treatment of ICU patients are very high. Fourth, ESAs are not legally approved for general use in ICU patients. Solely in distinct cases, such as Jehovah's Witnesses who refuse allogeneic blood transfusions due to religious beliefs, ESAs may be considered an exceptional therapy.

Microbiological surveillance and parenteral antibiotic use in a critical care unit

OBJECTIVE

To evaluate parenteral antibiotic utilization and bacterial resistance patterns in a critical care unit (CrCU).

DESIGN

Descriptive, prospective audit of infection site, culture and antimicrobial susceptibility test results, parenteral antibiotic usage and duration, total antibiotic acquisition costs, and length of stay.

SETTING

A 17-bed medical-surgical CrCU in a tertiary care teaching hospital in Metropolitan Toronto.

PATIENTS

Two hundred and fifty-eight patients admitted to the CrCU between May 1995 and April 1996 who received antimicrobial therapy.

RESULTS

The most frequently prescribed antibiotics were cefazolin (47%, 1098 g), gentamicin (33%,141 g) and ceftriaxone (20%, 255 g). The most common indications for antimicrobial therapy included surgical prophylaxis (34%) and pneumonia (35%). The following organisms were isolated from patients treated with antibiotics: Staphylococcus aureus (26%), Pseudomonas aeruginosa (13%), enterococci (12%), Haemophilus influenzae (11%), Escherichia coli (11%), Enterobacter cloacae (8%) and other Gram-negative bacilli (19%). Only 9% of Gram-negative bacilli were resistant to aminoglycosides, 3% were resistant to ciprofloxacin and no extended-spectrum beta-lactamases or imipenem-resistance were detected. No vancomycin-resistant enterococci and only two methicillin-resistant Staphylococcus aureus isolates were identified.

CONCLUSIONS

Antibiotic use during the audit appeared appropriate for the specific clinical indications. Low levels of bacterial resistance were detected during the audit.