The International Journal of Critical Care is the official journal of the World Federation of Critical Care Nurses. It builds on the legacy and successes of Connect, the former Journal, and endeavors to be a global vehicle for sharing the latest research, initiatives, policy advice, and achievements in critical care.
A Descriptive Exploratory Qualitative Study of Nurses’ Beliefs and Practices on End-of Life Care:
Objective: This study sought to develop a theory based on constructivism that described the experiences of nurses in caring for patients at the end of their life. The researchers endeavored to gather in-depth qualitative information of the participants’ cultural beliefs and practices that influenced their personal beliefs about dying and nursing practices related to the care of patients at the end-of-life. Method: The study utilized a qualitative descriptive exploratory research approach allowing for further understanding of the topic being explored and for the participants to contribute to the development of new knowledge in the area of EOL care. Data analysis was guided by the Grounded Theory method of Charmaz (2008). Data were collected through an interview among invited convenient samples of ICU nurses who were also participants of the CCNAPI webinar course and who represented various regions in the country. The intent was to investigate a phenomenon to have a better understanding of the existing beliefs and practices of Filipino nurses providing EOL care to ICU patients Result: There were 4 subthemes related to Pagkalinga (Care) and there were 5 subthemes that supported Pagdamay (Compassion). Three of the subthemes that identify with Pagkalinga namely Mixed Emotion, Attachment and Advocacy, and Spiritual Surrender are all Personal in category while the subtheme Collaboration and Communication is of an Institutional category. Moreover, three of the subthemes that support Pagdamay all belong to the Patient and Family category; only Caring Challenges belonging to a Personal category and Enhancing Institutional EOLC. Discussion (The General Theory): The participants’ personal experiences of EOLC resulted in the thematic analysis providing the foundation for analyzing qualitative data to support the emerging theory of “Pagkalinga and Pagdamay” (Care and Compassion). It is in this light that the emerging theory developed from the values of caring and compassion is expected to engender a competent EOLC practice Conclusion: The study concludes that a successful or dignified death experience is not an individual enterprise but a collaborative endeavor among the care giver (nurse), care receiver (patient and family), and care protector (system or institution), guided by a strong value system where the moral principles of Pagkalinga and Pagdamay are primordial in achieving desired goals such as a dignified closure to life and a successful death experience.
Copyright (c) 2024 Maria Isabelita C. Rogado RN, MAN, DNSc, Remedios Fernandez RN, PhD https://creativecommons.org/licenses/by-nc/4.0
Cognitive and Technical Competencies of Nursing Professionals in the Application of the Mnemonic Fast - Hug - Bid "Quick Hug"
Background: The FAST-HUG-BID mnemonic is a checklist designed for critically ill patients. Aim: To determine the cognitive and technical competencies of nursing professionals in the application of the FAST-HUG-BID "Quick Hug" mnemonic applied to patients in Critical Care Units of the Private Banking Health Fund in La Paz. Methodology: This research was organized using a cross-sectional study. Data collection took place during the first semester of 2022. The study area was the Private Banking Health Fund, Obrajes Zone in the City of La Paz. Results: More than 75% have 5 or more years of work experience, and 42% have a Master's degree. Regarding knowledge and practice, the level of knowledge evaluated is minimal in 50% of subjects (χ² = 7.7, P-value < 0.05), accepting the null hypothesis that knowledge and techniques are important factors in the quality of care. The knowledge and technique required to properly apply this mnemonic by professional staff represent one of the best strategies to ensure high-quality nursing services. Conclusions: These results underscore the critical importance of closing the gap between academic training, work experience, and the practical application of specific tools such as FAST-HUG-BID in critical care units. Despite having experienced and highly educated staff, the lack of practical knowledge in this specific area suggests the need for more effective and focused continuous education strategies, as well as regular competency assessment to ensure the highest quality in ICU nursing services.
Copyright (c) 2024 Soledad Calle; Virgina Troche https://creativecommons.org/licenses/by-nc/4.0
Distant Organs Complications Post Traumatic Brain Injury (TBI)
Background: Central Nervous System (CNS) plays integral role in controlling body organs, there is a constant interplay of neurotransmitters between CNS and extracranial organs. Hence, an isolated traumatic brain injury may be associated with various physiological responses of other body organs. Extra cranial injuries such as polytrauma and infection may also be associated with changes of neuropathology in patients with TBI. The aim of this paper is to highlight the systematic organs complications post TBI. Methods: A literature review of extracranial organs complications post TBI was conducted. Literature review findings were presented in a lecture format, using head to toe systematic assessment format. Starting with changes in pituitary gland, followed by heart and lungs changes, then gastro-intestinal and renal changes as well as a brief on immune system changes. The main mechanism of these physiological changes was discussed such as inflammation, catecholamine surge, and increased sympathetic tone affecting systematic organs. Result: Literature identified pituitary changes in up to 47% of traumatic subarachnoid hemorrhage. Hormonal insufficiency and antidiuretic hormone secretion abnormalities are the most common forms of pituitary dysfunction in patients with TBI. Diabetes Insipidus is reported in up to 51% of TBI cases, and it is associated with 57% to 69% mortality rate among patients with TBI. Cardiac dysfunctions are reported in up to 74% of TBI cases in which ECG abnormalities are the most common form of cardiac changes. Cardiovascular failure was reported on 18% of TBI cases. Catecholamines surge leads to structural change in cardiomyocytes due to direct effect of norepinephrine on cardiac muscles. Severe dysregulation of catecholamine homeostasis affects pulmonary vessels leading to increased blood pressure and generates massive blood shifts to the pulmonary vasculature causing Neurogenic Pulmonary Edema (NEP). In contrast, NPE can further the harm of the brain due to hypoxia and inadequate oxygen supply to brain cells. Brain injury insults the renal system indirectly in the form of electrolytes disturbances such as hypo and hyper natremia. Hyponatremia is reported in 51% of TBI cases. Stress ulcer is the most common form of gastrointestinal system changes among patients with TBI. In addition, CNS injury stimulates the immune system leaving patients with TBI highly susceptible to infection due to release of pro-inflammatory cytokines such as IL-1, IL-6 and TNF-α. Systematic inflammatory response state impacts organs hemostasias resulting on tissue hypoperfusion. Conclusion: Cerebral injury is not only a brain disease, but it also affects the body as whole leading to systematic changes that require holistic therapeutic approach to manage. Autonomic imbalance caused by CNS dysfunction may lead to various systematic complications. Understanding the mechanism of extra-cranial organs injuries are key to prevent and manage complications. Elevation of inflammatory biomarkers such may predict mortality and morbidity in patient post TBI.
Copyright (c) 2024 Maha Aljuaid https://creativecommons.org/licenses/by-nc/4.0
The Integration Experience as a New Graduates at a Private Hospital
The integration experiences of new graduate nurses in hospital settings are an important area of study that presents both concerns and opportunities. The transition from student to nurse is a critical period that significantly impacts a nurse's career development. This transition can be challenging as new graduates adjust from a student mindset to the responsibilities of being a nurse. Nursing students typically learn in a supportive environment with knowledgeable tutors and instructors who guide their decision-making. However, due to higher patient acuity and nursing shortages, the orientation period for new graduate nurses is often shortened, requiring them to quickly adapt to working independently. This transition may present challenges for new graduate nurses, including high stress levels, feelings of inadequacy, difficulty in applying theoretical knowledge in practical settings, as well as feeling overwhelmed and worried about making incorrect decisions. The aim of this research is to explore the experiences and perceptions of new graduate nurses during their integration process at a private hospital. Specifically, the study focuses on the challenges they face during this transition and how these challenges are addressed. Additionally, the research assesses the overall satisfaction of new graduate nurses with the integration program and examine how the program impacts their skill development and confidence. To gather data, a qualitative descriptive design was employed, utilizing semi-structured interviews with new graduate nurses who have been deployed at a private hospital for a period of 6 months to 1 year. The participant selection utilize a purposive sampling technique, focusing on Nursing Graduates from OCHS, SQU, Nizwa University, and Buraimi University. The interviews explored several themes related to the integration process, including orientation, support from preceptors and colleagues, workload, and opportunities for professional growth. The findings from the research were categorized into four main themes. The first theme captured the initial impressions and experiences of the new graduate nurses, including their enthusiasm, teamwork, practical experience, challenges with understanding the dynamic workplace, lack of confidence, and feelings of shyness. For instance, participants have expressed difficulties in understanding the hospital system and memorizing medication, names of doctors, and various items. E,g, “at the beginning it was difficult for me to understand the hospital system as well as memorize medication, names of doctors, and items” The second theme has focused on the challenges encountered by the new graduate nurses and how they managed them. Participants discussed the importance of being patient, good communication skills, studying, seeking help from others, and gradually handling an increasing number of patients per shift. For example, after three months, participants have mentioned their ability to work independently with more than 3-4 stable patients. Participants have provided feedback on their satisfaction with the integration program and its impact on their skill development and confidence. This feedback has revealed increased efficiency, skill and knowledge development, leadership growth, and gained confidence resulting from the program. For instance, participants have expressed how the program influenced their confidence and competency. They have acknowledged learning various nursing procedures and their ability to implement them independently. E.g. “It was very influenced; I became more confident” , “I learned many nursing procedures; I implemented them by myself” The insights gained from this study will have significant implications for nursing practice. The findings will provide a detailed understanding of the integration process at private hospitals and identify factors that facilitate or hinder the successful integration of new graduate nurses. This knowledge can be used by hospitals and nursing administrators to enhance their integration programs and ensure a smoother transition and increased confidence among new graduate nurses in the clinical setting. Providing support, empowerment, and engagement to new graduate nurses, as well as adjusting orientation programs for optimal effectiveness, is crucial. By creating a comfortable environment, hospitals can enable new graduate nurses to thrive, seek answers to their questions, and address any anxieties they may experience. Moreover, this study will contribute to a broader understanding of the nursing profession and its impact on career aspirations, self-awareness, and problem-solving skills.
Copyright (c) 2024 Khadija Al Busafi https://creativecommons.org/licenses/by-nc/4.0
An Emergency and Critical Care in Resource-Limited Settings: An Integrated Workable Concept Piloted in Cameroon
Background Critical illness results in millions of deaths throughout the world (Schell etal.,2018). There are an estimated 45 million cases of critical illness globally each year and 8.6 million premature deaths occurred in low-income and middle-income countries from causes that should not occur in the presence of timely and effective healthcare. Care for those with critical illness is often neglected due to lack of prioritization, coordination and coverage of timely identification and lifesaving treatments (Schell et.al. 2018). The vast majority of critically ill patients are cared for in emergency units and general hospital wards, rather than in intensive care units. Improving the care provided to these critically ill patients is urgently needed to reduce mortalities. When resources are limited, complex, advanced intensive care units with expensive monitoring and supportive equipment with large numbers of highly trained staff is unlikely to be feasible to scale-up to all and alternative approaches are required. In this abstract, description a recently developed concept of training and implementation of emergency and critical care in developing countries that could be done for resource limited settings with brief discussion of what has been piloted in Cameroon. The Concept of Emergency and Critical Care Piloted in Cameroon. Critical illness, in its broadest definition, is any immediately life-threatening, reversible condition. It can occur in any ill person and can start in the community or hospital and does not respect the underlying pathology or divisions in medical specialties. In the current concept health equity has been put at heart where everyone who is critically ill, deserves to survive from the illness and every stakeholder should be concerned about this care at all levels of the health pyramid. The current training concept focuses on training everyone on the foundations(essentials) of emergency and critical care while at same time support the large numbers of staff to implement this at the bedside with supportive evidence. 60 trainers were trained as a train-the- trainer approach, who then trained over one thousand clinical staff at different hospitals across the country in just one year. This concept trains nurses, midwives, anesthetist, physicians and others on same concept of essentials of emergeny critical care, then less staff trained at intermediate and advanced levels. Follow-up Implementation is followed up by a mentorship team put in place to continue to support the trainees in implementation. As well selected hospitals are supported in developing new intensive care units. Though more energy is focused on the essentials of emergency and critical care , advanced emergency and critical care is not neglected in this concept. The concepts covers all hospitals and units from primary healthcare to specialist hospitals. References Schell, C.O., Gerdin Wärnberg, M., Hvarfner, A. et al. The global need for essential emergency and critical care. Critical Care 2018;22:284.
Copyright (c) 2024 Daniel K Ntogwiachu https://creativecommons.org/licenses/by-nc/4.0
Interventions Supporting New Graduate Nurse Transition into Critical Care: A Systematic Review
Background: New graduate nurses have reported feelings of disorientation, discouragement, overwhelm and lack of confidence as they transition from nursing school to the practice environment. These feelings and a poor transition to practice can lead to burnout and turnover. New graduate nurses generally have a high turnover risk. Given the demands of specialty nursing practice environments like the intensive care unit, new graduates transitioning to critical care may be at an even higher risk of a poor transition to practice and risk of turnover. Aims: To present preliminary findings from a systematic review that aimed to identify, describe and report on the effectiveness of interventions that support new graduate nurse transition into critical care settings. Methods: A systematic review modelled on Joanna Briggs Institute methodology was designed. A systematic, peer-reviewed search was conducted in the following databases: OvidMEDLINE ALL, Embase Classic+ Embase, PsychINFO on OVID, CINAHL and Education Source on Ebsco, Nursing and Allied Health and ERIC databases, in addition to a grey literature search. For inclusion, the population of interest was new graduate nurses and all forms of intervention about transitioning new graduate nurses into critical care clinical practice were considered. Contexts of care encompassed all critical care settings as well as emergency departments. Findings: At this stage of the review, twenty-six articles met inclusion criteria encompassing interventions implemented in four countries: USA, Canada, China and Australia. Findings related to intensive care units as well as emergency departments were reported. All interventions were unique in nature resulting in a significantly heterogeneous sample. Where qualitative designs were used, four synthesized themes were generated. Conclusions: Preliminary review findings suggest that, to date, interventions implemented to support new graduate nurse transition into intensive care unit and emergency department contexts are unique and thus heterogeneous in nature. Despite the heterogeneity, common intervention elements are discernable and provide some direction regarding practices that support new graduate transition into critical care.
Copyright (c) 2024 Brandi Vanderspank-Wright, PhD RN CNCC(C) https://creativecommons.org/licenses/by-nc/4.0
Nursing Presence During End-of-Life Care in the ICU with a Focus on Discontinuing Mechanical Ventilation
Background: In certain jurisdictions around the world, the withdrawal of life-sustaining measures is part of end-of-life care in the intensive care unit. Nurses, as primary providers of care, are often active participants in the coordination and actualization of the withdrawal process. The withdrawal of mechanical ventilation is arguably one of the more complex aspects of the withdrawal process. Aims: To review current published professional literature on the topics of intensive care nurses’ experiences of withdrawing of life-sustaining measures (Vanderspank et al., 2018) and withdrawing mechanical ventilation for compassionate means (Efstathiou et al., 2020), as well as explore the ways in which certain jurisdictions, namely Canada, have sought to standardize withdrawal of life-sustaining measures processes (Healy et al., 2020). Methods: First, a detailed overview of the findings of a qualitative evidence synthesis on nurses’ experiences of withdrawing life-sustaining measures is presented (Vanderspank et a., 2018). Second, a systematic review and narrative synthesis of “perceptions, experiences and practices” of compassionate withdrawal of mechanical ventilation is described (Efstathiou et al., p. 1140X). The latter review was registered with PROSPERO (CRD42018086495) and modelled on a Cochrane approach. The search, with a phenomenon of interest being all forms of terminal withdrawal of mechanical ventilation, was executed in the following databases Medline and Medline in Process (via Ovid), Embase Class + Embase (via Ovid), Cochrane's Central Registry for Randomized Controlled Trials CENTRAL (via Ovid) and Cumulative Index of Nursing and Allied Health Literature (CINAHL, via EBSCOHost). Third, a Canadian initiative that included the development of a framework and a toolkit for the withdrawal of life-sustaining measures, was discussed. Findings: Specific to the Efstathiou et al. (2020) systematic review, 25 manuscripts were ultimately included in the review comprised of qualitative and qualitative designs as well as one Delphi study and encompassed findings from nine countries. The synthesized findings were reported under four themes. Conclusions: Death and dying is a reality of critical care practice. In jurisdictions where the withdrawal of life-sustaining measures is practiced, particular attention can be paid to the complexity of mechanical ventilation discontinuation for compassionate means. Critical care nurses demonstrate practice expertise related to the withdrawal of life-sustaining measures and their expert nursing knowledge and care has impact on the patient and family experience of death and dying in the intensive care unit. Regardless of jurisdictional practices, high-quality, end-of-life care is possible in the critical care context. References Efstathiou N, Vanderspank-Wright B., Vandyk A, Al-Janabi M, Deham Z, Sarti A, Delaney J, Downar J. Terminal withdrawal of mechanical ventilation in intensive care units: A systematic review and narrative synthesis of perceptions, experiences, and practices. Journal of Palliative Medicine. 2020;4(9): 1140-1164. doi: 10.1177/0269216320935002. Healy A, Hartwick M, Downar J, Keenan S, Lalani J, Mohr J, Appleby A, Spring J, Delaney J, Wilson LC, Shemie S. for Canadian Blood Services, the Canadian Critical Care Society, the Canadian Association of Critical Care Nurses, and the Canadian Society of Palliative Care Physicians. Canadian Journal of Anesthesia. 2020;67:1549 – 1556. https://doi.org/10.1007/s12630-020-01774-6 Vanderspank-Wright B, Efstathiou N, Vandyk AD. Critical care nurses’ experiences of withdrawal of treatment: A systematic review of qualitative evidence. International Journal of Nursing Studies. 2018;77:15-26. doi: 10.1016/j.ijnurstu.2017.09.012.
Copyright (c) 2024 Brandi Vanderspank-Wright https://creativecommons.org/licenses/by-nc/4.0
Developing Specialty Nursing Education in Oman
Nursing is a respected profession that aims to blend scientific knowledge and specialized skills to deliver high-quality healthcare services to patients and other individuals. In the Sultanate of Oman, a country situated on the southeastern coast of the Arabian Peninsula in Western Asia, nurses have the responsibility of taking care of patients and maintaining the quality of nursing care. The Oman government considers nursing to be a vitally significant profession, to be developed continuously as part of a vibrant healthcare topography of continuous improvement. This ethos underpins work on Oman’s standards of higher education and international standards of nursing education (Al Maqbali et al., 2019) Nurses in Oman make up the majority of the healthcare force; and approximately 60% of all healthcare professionals ( Ministry of Health, 2022). An educated and competent nursing workforce is vital for meeting national demand and maintaining quality in healthcare. Omani colleges and institutes with nursing faculties recruit doctoral nursing faculty members from different countries, and the MoH has collaborated with the Ministry of Higher Education (MHERI) to sponsor many Omani nursing professionals to obtain their PhD degrees from respected global universities, including in Australia, Canada, Ireland, the UK, and the USA. Despite the development of nursing and nursing education in Oman, like other counties, it faces a global shortage of nursing practitioners and academics. Currently, there are three universities in Oman implementing undergraduate nursing education under the umbrella of higher education and awarding bachelor’s degrees. An MSc in nursing is now offered at the national flagship higher educational institution, Sultan Qaboos University. In addition, The MoH has a College of Health Sciences based in Muscat, with eight branches in each region of Oman, offering bachelor’s degrees in nursing. In addition, there is a Higher Institute of Health Specialties (HIHS) in Muscat offering specialty postgraduate diplomas in different specialties for graduate registered nurses. It has nine nursing programs: Adult Critical Care Nursing (ACCN), Emergency Nursing (EN), Critical Care Nursing in Pediatric and Neonatology (CCNPN), Nephrology Nursing (NN), Midwifery Nursing (MN), Mental Health Nursing (MHN), Community Health Nursing Practice (CHNP), Infection Prevention and Control (IPC), and Health Services Management (HSM). From the above list, the ACCNP was particularly designed to improve the knowledge, skills, and attitudes of nurses working in critical care areas, such as the intensive care unit coronary care unit and post-cardiac surgery units, and to maximize the quality of care. ACCNP was initiated in the academic year 2004-2005, in partnership with faculty members from the University of Central Lancashire in the UK for three years (2004 to 2007), after which it was administered fully by the ACCNP faculty members at HIHS. The curriculum of ACCNP covers different competencies required for graduates, aligned with the main graduate attributes of HIHS. The impact of the training is measured by HIHS for each cohort, to maintain quality standards and improve the learning and teaching process. References Al Maqbali MR, Al Omari O, Slimane SBA, Balushi NA. The nursing profession in Oman: An overview. Nursing Science Quarterly. 2019;32(4):322–325. https://doi.org/10.1177/0894318419864346 Ministry of Health. Annual health report, 2022. https://www.moh.gov.om/documents/274609/7264771/Annual+Health+Report+2022/47623227-57f9-d9b7-372b-f16d8af6d91f
Copyright (c) 2024 Asiya Al Hasni, PhD, RN https://creativecommons.org/licenses/by-nc/4.0
Improving Compliance to Clinical Alarm Safety in Adult ICUs of a Tertiary Hospital in India
With increasing number of devices with alarms a corresponding increase in clinical alarm-related adverse events was witnessed in ICUs of given hospital. Events like missing of vital alarms, not responding promptly and indefinite suspending alarms, etc., were on rise. Checking alarm settings before admitting patient to ICU was not being routinely followed, at times alarm settings of previously admitted patients being followed for new patient. ICU audits revealed that alarm settings for vital equipment like cardiac monitors & Ventilators were inconsistently documented (only 60%). The absence of appropriate documentation was identified as a safety threat. For instance, for ICU patients transferred-out to wards on non-Invasive ventilator (BiPAP), healthcare providers were not able to effectively manage alarm triggers due to lack of clarity regarding device settings. A survey conducted among nurses (n-131) indicated that alarm fatigue had set in, indicating high numbers of false alarms, leading to actionable alarms not being promptly responded to. Another survey for ICU patients (n=20) elicited that 45% patients experienced unbearable noise levels with 75% citing high noise levels to equipment alarms. The need for streamlining gaps led to rigorous brainstorming by relevant team members and designing of a protocol for clinical alarm safety. It involved identification of devices that triggered vital alarms, standardization of volumes & tone of alarms as per urgency, creation of default settings for cardiac monitors & need for documentation of ventilator as well as BiPAP settings by Clinicians, including the change of settings. Central monitoring system was uniformly installed in ICUs. The protocol further required nurses to: (1) ensure adequate skin preparation before ECG lead application; (2) check all device alarm settings, leads and all connections on patient admission to the unit & start of every shift; (3) ensure updating of patient demographics on devices with each new patient, (4) change defective equipment & accessories as indicated; (5) escalate to Clinicians the need to change settings for acceptable deviation of patient’s vital parameters. ICU team was alerted against suspending alarms without valid Clinician’s prescription. Biomedical team performed weekly alarm checks and conducted equipment trainings with added focus on clinical alarm troubleshooting. Additionally, training was imparted on: possible reasons for alarms, priority-wise responding to alarms, escalation of patient condition as per need, monitoring and management of patients on transit with critical equipment support. Post implementation of protocol there was improvement in compliance to alarm safety in adult ICUs, which increased from 61.42% (Nov-2023) to 90.25% (April-20240). Alarm related incidents reduced from an average of 1.54 per month to 0 post implementation of protocol. The protocolling and standardization brought about improvement in clinical alarm safety in adult ICUs with zero instances of alarm-related adverse events. Considering the improvement in adult ICUs, the protocol was extended to pediatric ICUs with creation of age-based default device alarm settings.
Copyright (c) 2024 Minimole Varghese RN, Bincy Sunil Thomas RN https://creativecommons.org/licenses/by-nc/4.0
Outcomes Of Nurses Led Community-Based Intensive-Phase Drugs Resistant Tuberculosis (DR-TB) Treatment Pilot in Montserrado, County, Liberia
Background: TB Annex Hospital was the only center in the country treating DR-TB in 2017 after Ebola, when the community-based intensive-phase multi-drugs resistant tuberculosis treatment was piloted in Montserrado, County to decongest the DR-TB ward and improve treatment outcomes. To date, there are only two hospitals providing treatment for DR-TB in the country. Intervention: The intervention of the study was to evaluate the implementation of community-based intensive-phase of DR-TB treatment pilot project in Montserrado County that would inform the decentralization of DR-TB treatment centers to mitigate the disease burden. Methods: A prospective cohort study with real-time data collection, where six DR-TB patients were enrolled into the community-based intensive treatment phase for a period of six to seven weeks (01 July to September 2017). All the patients spent about six months in the TB Annex Hospital before transitioning into the community-based treatment pilot. Results: Six DR-TB patients (3 or 50% males, 3 or 50% females for Rifampicin were recruited during the study period, with 100% (6/6) recovery rate during the pilot; no defaulter nor death. The patients’ age ranged from 20 years to 35 years, with mean age of 26 years. Half (50%) of the patients were between the ages (25-29 years). The average length of stay in the initial phase of treatment (i.e. in the TB Annex Hospital) was 224 days or 8 months, while the minimum and maximum days were 155 and 195 days respectively. On the other hand, the average days spent by patients during the home-based treatment were 41 or 6 weeks, while the minimum and maximum days were 33 and 51. Conclusion: Addressing tuberculosis is one of the major priorities for the Ministry of Health and key health partners in Liberia, there are both human resource and limited human resources and health facilities to manage patients according to standard treatment guidelines. Once patients are stabilized and have at least two-three (3) consecutive negative AFB smears; they can be safely transitioned to home-based or community-based treatment, with active involvement of stakeholders, including nurses, doctors and other family care givers. This helps in reducing crowdedness and workload for staff in facility with limited bed occupancy while promoting health and well-being of patients. Although the sample size used in the study is fewer to generalize the findings, it is important to consider the lessons learnt from the pilot when decentralizing DR-TB treatment in Liberia. There is also a need to increase the awareness of this using the print, electronic and social media to get the message across to the community dwellers. Additionally, getting the community health workers involve is an added benefit.
Copyright (c) 2024 Shirley S. Fahnbulleh, Lydia Z. Mianue, RN https://creativecommons.org/licenses/by-nc/4.0
Can Integrity be Safeguarded? Factors Predisposing to Non-Invasive Ventilation Associated Skin Injury (NASI)
Introduction: Over the last two decades, there has been a significant increase in the use of non-invasive ventilation (NIV) therapy. However, this therapy has been linked to the development of pressure injuries in 10% to 31% of patients, with 5% to 20% of these cases resulting in nasal bridge pressure ulcers. Safeguarding skin integrity in patients on NIV is essential, yet challenging due to factors such as mask pressure, duration of use, and patient skin sensitivity. This study aims to identify and analyse the factors predisposing patients to NASI to develop better preventive strategies. Objective: The primary objective of the study is to identify factors contributing to Non-invasive ventilation Associated Skin Injury (NASI) in patients on the non-invasive ventilator. Material & Methods: A descriptive cross-sectional survey design was adopted.70 patients on non-invasive ventilation (NIV) therapy were recruited for the study. The sampling technique employed was non-probability purposive sampling. Ethical permission was obtained from the local IRB and written informed consent was taken prior to the study. Observation Checklist was used and data was analysed using descriptive statistics. Results & Analysis: The findings suggest that majority (37%) patients were above 78 years and 33% between 39-58 and 30% belong to 59-78 years respectively. Mean age is approximately 65.4 years. The incidence of NASI was noted in 33 % patients and 67% patients did not have any signs and symptoms of NASI. Varying degrees of skin injury was observed in patients with incidence of NASI, 16% experienced first-degree Noninvasive Ventilation Associated Skin Injury (NASI), 12% experienced second-degree NASI, and only 5% were diagnosed with third-degree NASI. High-frequency factors identified were incorrect positioning or size of the mask, lack of protective skin barrier, infrequent assessment and lack of communication prior to application. Discussion: This study's findings highlight several factors that predispose patients to NASI. Key among these are the duration of NIV therapy, the type and size of the mask, and patient-specific factors such as skin sensitivity and underlying health conditions. Conclusion: Prevention of NASI requires a multifaceted approach, including regular skin assessment, appropriate interface selection, padding and securing interfaces adequately, optimizing fit and positioning, implementing pressure relief strategies, maintaining skin hygiene, providing patient education, and fostering interdisciplinary collaboration among healthcare professionals.
Copyright (c) 2024 Pooja Jayan Nair, RN https://creativecommons.org/licenses/by-nc/4.0
Bundling Care in Comatose Post Cardiac Arrest Patients
Post cardiac arrest syndrome (PCAS), an inflammatory state resulting from an ischemia-reperfusion injury impacting multiple organ systems. Hospital teams from the ED to Cath Labs to the ICU must practice in synchrony to optimize care. Key priorities in patients who remain comatose following return of spontaneous circulation are imperative to reduce the impact of PCAS. The team must focus on interventions and coordinated care to limit the damage of reperfusion injury to the brain/body. The complexity and heterogeneity of this patient population presents the team with challenges related to time, place, intervention sequence and elements. This presentation will focus on delivering care to the cardiac arrest and comatose post-cardiac arrest patient, selecting interventions maximizing oxygenation/ventilation and hemodynamics while implementing the strategies of TTM, Neurologic care, seizure surveillance, and management to lessen the pathologic impact of PCAS in the form of bundles of care. Target goals, interventions, and outcomes for the bundle elements will be shared.
Copyright (c) 2024 Mary Kay Bader https://creativecommons.org/licenses/by-nc/4.0
Nurse Care Post Thrombolysis and Thrombectomy in Stroke
Patients presenting with an acute ischemic stroke must be identified quickly so the stroke team can provide emergent care. From the emergent phase in the Emergency Department (ED) to the diagnostic/operative phase in Interventional Radiology (IR) to the intensive care unit (ICU), nurses must be knowledgeable and involved in the care of the acute stroke patient. ICU nurses must know the standards for stroke centers, evidenced-based literature for intervening with stroke patients in ED & IR and the continuum of care. Nurses care priorities in the post thrombolysis and post thrombectomy period include critical reassessments of the neurologic system and vital signs. This session focuses on the hyperacute ischemic stroke patient presenting within 24 hours of symptom onset. Nurses must be prepared to understand assessment priorities in the stroke patient, manage patients with intravenous thrombolytics with the goal to deliver the drug in under 30 minutes and manage care in the IR suite and ICU post thrombectomy with the aim prevent complications and maximize clinical outcomes.
Prone Positioning: Examining a Key Supportive Strategy in ARDS
Has your unit’s use of prone positioning in acute respiratory distress syndrome (ARDS) changed because of the pandemic? Evidence supports prone positioning benefits gas exchange, reduces ventilator induced lung injury and mortality. This foundational session discusses the physiological benefits of proning, when to initiate and how to perform it safely for the patient and staff. Strategies for incorporating lessons learned from the pandemic to consistently integrate prone positioning as a front-line strategy for ARDS are discussed. During the pandemic, proning was brought to light as a significant part of the treatment plan for patients with ARDS. However, prior to Coronavirus disease, only 16% of the world was using prone positioning for ARDS. Proning is indicted as front-line therapy for patients with severe ARDS defined as PaO2/FiO2 ratio of < 150mmhg with a FiO2 of at least 60% and positive end expiratory pressure of at least 5cm H2O. The health care team’s goal is focused on the right ARDS patient, at the right time and for the right amount of time. The first step is to outline indications and contraindications for the use of the position. A challenging component to using the therapy is the turning sequence and nursing the patient while in the prone position. Methods to reduce skin injury, ensure airway stabilization and prevent healthcare worker injury are critical to the adoption of the practice within an intensive care unit and are discussed. References Guérin, C., Reignier, J., Richard, J. C., Beuret, P., Gacouin, A., Boulain, T., Mercier, E., Badet, M., Mercat, A., Baudin, O., Clavel, M., Chatellier, D., Jaber, S., Rosselli, S., Mancebo, J., Sirodot, M., Hilbert, G., Bengler, C., Richecoeur, J., Gainnier, M., … PROSEVA Study Group (2013). Prone positioning in severe acute respiratory distress syndrome. The New England Journal of Medicine, 368(23), 2159–2168. https://doi.org/10.1056/NEJMoa1214103 Morata, L., Vollman, K., Rechter, J., & Cox, J. (2024). Manual Prone Positioning in Adults: Reducing the Risk of Harm Through Evidence-Based Practices. Critical Care Nurse, 44(1), e1–e9. https://doi.org/10.4037/ccn2023201 Vollman KM, Mitchell DA. (2024). Prone Positioning for Acute Respiratory Distress Syndrome Patients. In Johnson KL (ed): AACN Procedural Manual for Progressive and Critical Care. (8th ed). St Louis, Elsevier, 143-156.
Copyright (c) 2024 Kathleen M. Vollman https://creativecommons.org/licenses/by-nc/4.0
Implementing a Therapeutic Music Program in the ICU
Introduction: In an effort to promote a healing environment in the intensive care unit (ICU), the use of therapeutic music offers an opportunity to expand patient and family centered care initiatives. However, limited information is available on the benefits of therapeutic music for patients, family members and clinical staff. Objective: The objective of this study was to implement a therapeutic music program in the ICU setting. Using musicians who were processed as hospital volunteers, the program was implemented starting in the medical ICU and expanding to 4 other clinical ICUs at an academic medical center. Methods: Institutional review board approval for the study was received. Musicians provide live music several times a week, typically in the late afternoon, visiting patient rooms and playing music in the hallways for those patients with isolation precautions (Figure 1). The volunteer musicians play classical genre music songs for patients using a variety of instruments including piano, cello, viola, violin, oboe, flute, and saxophone. Non-identifiable data was collected from patients, clinical nurses, and musicians using Research Electronic Data Capture (REDCap) in several descriptive studies. Responses to five open ended questions assessed perceptions of the therapeutic music. The qualitative data was analyzed using NVivo, a qualitative data analysis computer software, to sort into themes. Results: Majority (92% ) of patients indicated that music was a significant part of their life and 90% indicated that they enjoyed the experience and would participate in the future. Clinical nursing staff and musicians highlighted the benefits of having live music for patients to provide a momentary disruption to the busy ICU environment. Major themes reflected the calming and relaxation effects of music, and the benefits of having live music played by musicians in the ICU. Conclusions: The results suggest that therapeutic music is beneficial in helping to promote a healing environment in the ICU. Additional ongoing research is exploring the impact of different music genres and the ideal exposure “dose” of therapeutic music, as well as the potential to impact patient outcomes including the development of delirium in the ICU. References: Bruder AL, Gururaja A, Narayani N, Kleinpell R, Schlesinger JJ. (2024) Patients' Perceptions of Virtual Live Music in the Intensive Care Unit. American Journal of Critical Care. 1;33(1):54-59. doi: 10.4037/ajcc2024140 Schlesinger JJ, Pearson M, O'Briant D, Bose J, Yang ST, Li J, Rice T, Kleinpel R. (2022) Implementing and Evaluating a Pilot Therapeutic Music Program in the Intensive Care Unit. International Journal of Critical Care;16:2. doi.org/10.29173/ijcc44
Copyright (c) 2024 Ruth M. Kleinpell PhD APRN-BC FAAN FAANP, Joseph J. Schlesinger, MD, FCCM, Akash Gururaja, MD; M.B. Michel https://creativecommons.org/licenses/by-nc/4.0
Implementation of Skin Care Formulary in View of Reduction of Patient Developing Pressure Injury Related to Incontinence-Associated Dermatitis in Surgical Intensive Care Unit-Rashid Hospital
Introduction: Incontinence-associated dermatitis (IAD), resulting from diarrhea and/or fecal incontinence, and perspiration and enzymatic wound drainage is a common problem in intensive care unit. Skin care formulary was used to treat patient with Moisture associated skin damage. The formulary served as a guide on skin care management products that were recommended to use at Rashid Hospital. The formulary was used as an educational tool, to promote evidence-based, safe and cost-effective recommendations of skin care products for Moisture damage. The formulary included a brief description of all the wound care materials approved by the Dubai Academic Health Corporation (DAHC) Aims: The project aimed to reduce the number pressure injury incident in surgical Intensive Care unit by improving staff knowledge about incontinence associated dermatitis and implementing skin care management products as per skin care formulary to prevent and treat IAD. Methods: A survey was conducted on staff’s knowledge on prevention of moisture associated skin damage – incontinence associated dermatitis. Team was formulated. Skin care formulary education was provided to each team member by wound care management department. All surgical intensive care unit staff was educated on Incontinence Associated Dermatitis, and implementation of skin care formulary to prevent and treat it. Products mentioned in the skin care formulary was made available in the unit. Audit was conducted to closely monitor the nurse’s practice in using these products by direct observation method for a period of 6 months. Nurses were communicated about patients who were high risk of developing IAD. Post education survey was conducted to evaluate Nurse’s knowledge and practice in implementation of the skin care formulary to prevent and treat IAD. Result: Before the implementation of the project, survey conducted revealed that 79.27% of nurses had full knowledge on prevention of IAD and about skin care formulary. After that the team conducted extensive education in the unit, post audit survey showed marked improvement with 100% staff nurses completely aware about skin care formulary and prevention of IAD. In the year 2020 and 2021, pressure injury related to MASD- IAD was 7 and 9 respectively. After the implementation of the project in the year 2022, pressure injury incident related to MASD- IAD significantly dropped to 3. In the year 2023, to maintain sustainability of the project it was adopted as a Best practice Initiative in the unit. During this phase re-education was done for all Nurses reinforcing the significance of implementing Moli care foam and Zinc oxide cream to prevent IAD. As a result, pressure injury related to IAD further dropped to 2 in the year 2023. Moli care foam Spray and zinc oxide cream played a vital role in prevention of skin breakdown of patient who are having diarrhea and/ or fecal incontinence. Conclusion: The project created an awareness about incontinence-associated dermatitis in the SICU. Staff knowledge improved by 20.73%. and subsequently, an aggregate reduction of pressure injury related to incontinence-associated dermatitis of about 9% was noted in the year 2022-2023 as compared to the year 2020-2021. A direct correlation was observed between staff knowledge and reduction of pressure injury related to IAD. Moli care foam spray and zinc oxide cream played a vital role in the prevention of skin breakdown of patients who are having diarrhea and/ or fecal incontinence.
Copyright (c) 2024 Aquino Eyao BSN-RN, MBA-HA,IIWCC https://creativecommons.org/licenses/by-nc/4.0
Exploring the Knowledge, Attitudes, and Practices of Critical Care Nurses in Iran towards Pressure Ulcer Prevention
Background Pressure ulcers (PUs) pose a significant health problem that can be prevented in various healthcare settings, particularly in intensive care units (ICUs). PU increases the risk of morbidity and mortality and is associated with poor prognosis in ICU patients. ICU prevalence rates for PU have been estimated to range from 21% to 39.3% worldwide (Coyer et al., 2022). According to a recent meta-analysis, the prevalence of PU in Iran's ICUs was 19.59% (Sohrabi Akhkand et al., 2020). Despite these alarming facts, PU is often preventable with adherence of healthcare providers to evidence-based PU prevention guidelines. One of the most important factors influencing PU prevention is adequate knowledge of ICU nurses to evaluate and manage risk factors and implement preventative approaches (Wu et al., 2022; Ghorbani Vajargah et al., 2023). Aims This study aimed to examine the knowledge, attitudes, and practices (KAP) of ICU nurses towards PU prevention in Iran. Methods In a multicenter cross-sectional study, after approval from institutional ethics committee (IR.MAZUMS.REC.1399.591) and written informed consent, 183 ICU nurses working in four hospitals affiliated with Mazandaran University of Medical Sciences in Sari, Iran, were evaluated. The study was carried out between July and October 2020. Data collection involved a four-part questionnaire consisting of demographic characteristics, the Pieker Pressure Ulcer Knowledge Test (PPUKT), the Attitude toward Pressure Ulcer Prevention (APUP) tool, and an assessment of nurses' practices related to PU prevention. Results The mean age of participants was 32.82 (SD = 5.93) years and the mean years of working experience was 8.26 (SD = 6.02) years. Of the nurses, 56.2% were female, 63.4% were married, 87.4% were residents in an urban area, and 76.5% had a BSN degree. The mean scores for ICU nurses' KAP regarding PU prevention were 70.57 (SD = 13.51), 52.82 (SD = 6.16), and 22.44 (SD = 5.20), respectively. As presented in Table 1, a positive correlation was observed between nurses' attitudes and their practices (r = 0.232, P = 0.002), while a negative correlation was found between their knowledge and attitudes (r = -0.156, P = 0.035) towards PU prevention. Also, the results showed a positive correlation between the years of ICU work experience among nurses and their knowledge of PU prevention (r = 0.159, P = 0.032). The same result was also observed for the overall years of working experience, although this correlation was marginally significant (r = 0.145, P = 0.051). Based on a one-way ANOVA, there was a direct relationship between knowledge and income, and knowledge were higher in high-income nurses (P = 0.017). Table 1: Means, Standard Deviations, and correlations among study variables. Descriptive statistics Correlational analysis Possible range Observed range Mean (SD) Knowledge Attitude Practice Knowledge 0-100 39.02-100 70.57 (13.51) 1 Attitude 0-100 32.69-67.31 52.82 (6.16) -0.156 1 Practice 0-44 10-37 22.44 (5.20) -0.119 0.232 1 Conclusion The findings of this study indicate that the KAP levels of Iranian ICU nurses regarding PU prevention were desirable, positive, and relatively desirable. Therefore, it is recommended that nurse managers and policy makers address the major barriers and related factors that may affect ICU nurses' practices in preventing PUs. References Coyer F, Labeau S, Blot S. (2022) Preventing pressure injuries among patients in the intensive care unit: insights gained. Intensive Care Medicine. 48(12):1787-1789. https://doi.org/10.1007/s00134-022-06838-3. Ghorbani Vajargah P, Mollaei A, Falakdami A, Takasi P, Moosazadeh Z, Esmaeili S, Emami Zeydi A, Karkhah S. (2023) A systematic review of nurses' practice and related factors toward pressure ulcer prevention. International Wound Journal. 20(6):2386-2401. https://doi.org/10.1111/iwj.14062. Sohrabi Akhkand S, Seidi J, Ebadi A, Ghanei Gheshlagh R. (2020) Prevalence of pressure ulcer in Iran’s intensive care units: A systematic review and a meta-analysis. Nursing Practice Today. 7(1) doi.org/10.18502/npt.v7i1.2296 Wu J, Wang B, Zhu L, Jia X. (2022) Nurses' knowledge on pressure ulcer prevention: An updated systematic review and meta-analysis based on the Pressure Ulcer Knowledge Assessment Tool. Frontiers in Public Health. 10:964680. doi.org/10.3389/fpubh.2022.964680.
Copyright (c) 2024 Amir Emani Zeydi, Samad Karkhah, Saman Maroufizadeh, Mohammad Hashem Gholampour, Mohammad Javad Ghazanfari https://creativecommons.org/licenses/by-nc/4.0
Advancing Critical Care Nursing: Navigating Artificial Intelligence (AI) and Machine Learning (Ml)
As the healthcare sector stands on the brink of a technological revolution, critical care nursing faces the imperative and challenging task of navigating the integration of Artificial Intelligence (AI) and Machine Learning (ML) into its practices. This presentation delves into the transformative journey of incorporating these advanced technologies to enhance patient care, optimize workflows, and address the complexities of critical care environments. AI and ML are not just tools for innovation but are becoming essential components in the evolution of nursing care. They offer sophisticated solutions for real-time patient monitoring, diagnostic accuracy, and predictive analytics, contributing significantly to improved patient outcomes and operational efficiency. This presentation explores practical examples where AI and ML have been successfully implemented in critical care settings, demonstrating their potential to revolutionize patient care through personalized treatment plans, early detection of complications, and the reduction of manual tasks, thereby allowing nurses to focus more on patient care. Integrating AI and ML into nursing practice presents challenges such as ethical dilemmas, data privacy issues, the necessity for extensive training, and the development of cross-disciplinary teamwork. Overcoming these hurdles requires a focused approach: ongoing educational initiatives to enhance nurses' proficiency in AI and ML, strict adherence to ethical guidelines protecting patient information, and fostering teamwork across various healthcare domains to fully harness AI and ML's capabilities in critical care nursing. In conclusion, this presentation seeks to inspire and equip nursing professionals with the knowledge and tools necessary to lead the charge in adopting AI and ML technologies. By embracing these innovations, critical care nursing can advance to new heights of efficiency, precision, and patient-centric care, marking a new era in healthcare.
Copyright (c) 2024 Vimala Ramoo PhD, MEd, BNSc, CCN, RN. https://creativecommons.org/licenses/by-nc/4.0
Long-Term Outcomes After Sepsis and Septic Shock: Preliminary Findings of a Systematic Review
Background Every year, sepsis affects almost 50 million people worldwide, and 1/5 affected die. Survivors suffer long-term negative consequences. This presentation provides an overview of a review study on sepsis survivorship examining 4-outcomes. Aim The aim of this study was to explore long term outcomes after recovering from sepsis and septic shock. Method A systematic review method was used to search, identify, and appraise the available publications (Registration CRD42023343458). Primary studies on adult (≥18yo) sepsis survivors, published globally from 2012-2023 in English, Spanish and Portuguese were retrieved from SCIELO, Virtual Health Library, Pub med and EMBASE search engines. Outcomes of interest included cognitive and physical function, quality of life, and readmission. Studies on sepsis/septic shock survivors <18yo and non-primary research were excluded. Results The search strategy yielded n = 11,522 references retrieved, with n = 11,025 entries blindly screened for legibility after duplicates removed by two independent reviewers; n = 339 full texts were evaluated, with n = 73 included in the review. Studies were predominantly from North America, Europe and Australia. A handful of studies conducted in Brazilian population. Sepsis survivors have their cognition compromised from 3-months to 1-year after hospital discharge, they remain with different levels of physically impairment more than 3-years after a sepsis episode, with aged population reporting greater levels of dependence. At 5 years, sepsis survivors continue to experience physical quality of life scores when compared to controls. Almost 50% of sepsis survivors were readmitted within a year after hospital discharge. Conclusion Sepsis survivors experience lasting cognitive and physical consequences, readmission is common within a year of a sepsis episode. These impairments affect their quality of life. Long term outcomes after a sepsis episode needs rigorous research, particularly in low- and middle-income settings.
Copyright (c) 2024 Laura Alberto, PhD, MEd, Esp.Ed., Com.Sc.(Dip), BN, Tracey Bowden, PhD, Kalliopi Kydonaki, PhD, Katerina Iliopoulou, PhD, Dolores Albor Vázquez, RN, Enrique Castro-Sánchez, PhD, Ania Yanina Castillo, PhD, Julie Robinson, MSc, Natalia Torres, BN, Leanne M Aitken, PhD, FAAN https://creativecommons.org/licenses/by-nc/4.0
The Adversities of Living With Renal Failure in Africa: The Lived Experiences of Patients Receiving Renal Replacement Therapy in Dodoma Tanzania
Background Chronic kidney disease (CKD) involves a progressive loss of kidney function due to damage to the epithelia and endothelia kidney cells, lasting at least 3 months (Kipp & Kellerman, 2008). It emerges as a global health concern as it affects an average of one in ten people and is listed among the top ten causes of mortality globally (Kovesdy, 2022). In Tanzania, CKD causes three times higher mortality than other diseases (Kilonzo et al., 2016). The impact of CKD on patient’s quality of life due to debilitating physical and psychological symptoms resulting from accumulation of toxins are known. Nevertheless, an overall picture of their complex adversity experiences, especially among patients with CKD in African region where there is disparity in access to services, poor transportation, and poor social-economics, remained a subject for further exploration. Purpose To explore the adversities of living with chronic kidney disease from the perspectives of their lived experiences among the patients with renal failure receiving hemodialysis treatment in Dodoma region, Tanzania. Design A phenomenological qualitative study design. Methods A total of 12 patients with CKD and receiving maintenance hemodialysis treatment at the Tertiary hospital in Dodoma city, Tanzania were purposively selected and participated in the face-to-face in-depth interviews. The data were audio-recorded, transcribed verbatim and analyzed using manifest thematic analysis approach. The findings are reported according to the consolidated criteria for reporting qualitative research (COREQ) checklist. Results Six themes emerged from the data that represented four major areas expressed as adversities that impacted negatively on their lives and two aspects as relieving factors. The four themes that depicted their negative experiences included (1) Unpleasant illness experiences, (2) Meaning constructed after having been diagnosed with CKD, (3) Social disconnection, and (4) Financial difficulties. The two relieving factors included (5) Satisfaction with hemodialysis treatment benefits and (6) Satisfaction with the strategies they invented as coping mechanisms. Conclusion: Participants expressed a sense of psychological shock, expressing no hope for a cure or good quality of life with CKD in this context. They expressed adversities, including social, economic, physical, and psychological struggles linked to renal failure that impact their quality of life. While the patients were the socioeconomic pillars of their families, being affected by CKD implied deprivation and increased burden to the families on these matters due to reduced or failure to engage in productivity/loss of jobs, relocation for treatment, weekly dialysis costs that would amount to USD 400 that they would hardly afford (Ang et al., 2022), and the perception of near death that could heighten their depressive mood (Bahall et al., 2023). We recommend that early screening of kidney injuries, malfunctions, or failure be performed at every health facility where initiation of early management can be done to prevent further damage. Patients with renal failure in the African context need closer support to enable them to live a better quality of life. References Ang YTI, Gan SWS, Liow CH, Phang CC, Choong HLL, Liu P. Patients’ perspectives of home and self-assist haemodialysis and factors influencing dialysis choices in Singapore. Renal Replacement Therapy. 2022;8(1):1–15. https://doi.org/10.1186/s41100-022-00430-7 Bahall M, Legall G, Lalla C. Depression among patients with chronic kidney disease, associated factors, and predictors: a cross-sectional study. BMC Psychiatry. 2023;23(1):881. https://doi.org/10.1186/s12888-023-05383-7 Kilonzo SB, Seiffudin AT, Bakshi FA, Gunda DW. Renal dysfunction among adult patients in Mwanza, Tanzania: Prevalence, outcomes and associated factors. Tanzania Journal of Health Research. 2016;18(3):1–8. https://doi.org/10.4314/thrb.v18i3.5 Kipp R, Kellerman PS. Chronic Kidney Disease. In Pathophysiology of Kidney Disease and Hypertension. Elsevier Inc., 2016. https://doi.org/10.1016/B978-1-4160-4391-1.50018-7 Kovesdy CP. Epidemiology of chronic kidney disease: an update 2022. Kidney International Supplements. 2022;12(1):7–11. https://doi.org/10.1016/j.kisu.2021.11.003
Copyright (c) 2024 Golden Mwakibo Masika MScN, PhD, Ansfrida Rwezaura Alfred, Rehema Bakari Omari https://creativecommons.org/licenses/by-nc/4.0
Global Consensus on Critical Care Nursing Research Priorities: A Modified Delphi Study
Background Some studies reported research priorities for adult critical care nurses (Egerod et al., 2020, George et al., 2020). However the changing nature of health systems and the recent pandemic raise the question of whether these findings are contemporaneous and internationally relevant. Protocol and progress on the study are provided in this presentation. Aim The aim of this study is to describe contemporary global research priorities in adult critical care nursing. Method A modified eDelphi method using a 4-round online survey is utilized with an expert panel of international critical care nurses (George et al., 2020, Iqbal and Pipon-Young, 2009). The e-Delphi is the most timely and cost-effective way to obtain consensus (Nasa et al, 2021). In the initial round, panel members were asked to indicate 5 research priorities. Findings from this round will be grouped thematically into survey items (research priority areas). In round 2, panel members will be asked to rate survey items using a 9-point ordinal scale to indicate strength of agreement. Items that do not achieve the pre-set consensus level, will be sent to panel members in a 3rd round. When all research priorities are identified, panel members will be asked to rank the research priorities (round 4) in terms of contemporary importance by placing them in order of importance. The World Federation of Critical Care Nurses global network will be used to identify a purposive sample of critical care nursing experts working in association with adult intensive care units (n = 100) (Williams et al., 2023). This study protocol was approved by the Ethics Committee of Hospital Alemán, Argentina (ProtV2-05-02-23/PRIISA17feb23). Conclusion Findings of this study will potentially be crucial for governments, academic institutions, and healthcare organizations to make decisions about research funding and needs. This will help to fill in the current gaps in the literature and may generate knowledge that improve patient care in the adult critical care settings.
Copyright (c) 2024 Laura Alberto PhD, MEd, Esp.Ed., Com.Sc.(Dip), BN, Paul Fulbrook, PhD, MSc, Post Grad Dip Educ, BSc(Hons), RN, Ged Williams AO, RN, Crit. Care Cert., LLM, MHA, FACN, FACHSM, FAAN, Mathilde Christensen, BN, MNurs Crit Care, Candelaria María Cafferata, RN, Dolores Albor Vázquez, RN, Isabel Coetzee-Prinsloo, PhD, MCur, Post Grad Dip Educ, Crit Care , Khalil. M Yousef, RN, PhD, Ruth Kleinpell, PhD, RN, FAAN https://creativecommons.org/licenses/by-nc/4.0
Digital Innovation in Personalized Aftercare
Admission to the intensive care unit (ICU) can be a challenging period for patients and their families as they navigate through complex medical treatments and emotional stressors. Among the complexities of critical medical interventions, navigating through the ICU experience can be overwhelming. Following discharge, the transition to post-ICU care is critical, necessitating comprehensive support and information dissemination to patients and their loved ones to ensure continuity of care. Recognizing the significance of this transition, there has been a concerted effort to harness digital innovations to augment support mechanisms for patients and their families during this critical period. Research has delved into the development and evaluation of digital tools tailored for post-ICU support. These digital platforms, accessible via various devices such as computers, laptops, tablets, and smartphones, offer a convenient means of delivering essential information and emotional assistance to patients and families post-discharge. By providing digital innovation, these tools aim to alleviate the emotional burden and enhance the understanding of post-ICU care procedures, facilitating a smoother recovery journey for patients and their support networks. The primary objectives of this research endeavor were multifaceted, including the identification of specific needs among ICU patients and their families during the post-discharge phase, delineation of pivotal components within digital post-ICU care, and exploration of cross-cultural variations in priorities and requirements for digital support systems post-discharge. The study, conducted across diverse healthcare settings in the Netherlands, Germany, the United Kingdom, and Croatia, aimed to provide comprehensive insights into the global landscape of post-ICU care and the role of digital interventions in optimizing patient outcomes and familial well-being.
Copyright (c) 2024 Ana Brčina RN https://creativecommons.org/licenses/by-nc/4.0
Pressure Injury Prevalence in Intensive Care Versus Acute General Patients: a 5-year Analysis
Background: ICU patients have multiple risk factors and are vulnerable to pressure injury. Previous studies have shown that pressure injury prevalence and incidence are high in ICU compared to non-ICU samples. However, few studies report mucosal injuries, and many exclude Stage 1 pressure injuries, making benchmarking difficult. Aim: To analyse state-wide prevalence of hospital-acquired pressure injury (HAPI) in ICU versus non-ICU patients. Method: Secondary data analysis of five state-wide annual point-prevalence studies between 2015 to 2019. Sample: N = 15678, ICU n = 611. Results: ICU HAPI prevalence = 9.6% (non-ICU = 2.1%; p < .001); ≥ Stage II ICU HAPI prevalence = 8.6% (non-ICU = 1.2%; p < .001); ICU patients 5 times greater likelihood to have a HAPI than non-ICU patients; ICU patients 7 times greater likelihood to have a ≥ Stage 2 HAPI than non-ICU patients. The proportion of ‘severe’ HAPIs (Stages III-IV and SDTI) in ICU (27.9%) was greater than non-ICU participants (14.4%); p = .004. The largest proportions of ICU HAPIs were on the sacrum/coccyx (20.9%) or heel (16.3%) and there was a significantly greater proportion of hospital-acquired mucosal injuries in ICU patients (1.6% versus 0.1%). Conclusions: The difference in HAPI prevalence between ICU and non-ICU patients was statistically and clinically significant. The relatively high prevalence of HAPI in ICU indicates that despite heightened awareness of prevention in ICU, they remain a significant clinical problem. Although prevalence was high in this Australian study, it compares favourably with other recent global studies. These results may be used for national and benchmarking.
Copyright (c) 2024 Paul Fulbrook RN PhD, Dr. Josephine Lovegrove, Professor. Fiona Coyer https://creativecommons.org/licenses/by-nc/4.0
Management of Decompensated Heart Failure in the ICU
In 2021, there were 56.5 million prevalent cases of heart failure globally, 27.3 million females, and 29.2 million males. Ischemic heart disease (33.8%), hypertensive heart disease (22.6%), and other cardiomyopathies (8.2%) were responsible for the most prevalent heart failure cases worldwide. Heart failure is not a single pathological diagnosis, but a clinical syndrome consisting of cardinal symptoms (e.g. breathlessness, ankle swelling, and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles, and peripheral edema). The objective of this presentation is to provide an overview of the strategies to manage patients with decompensated acute heart failure in intensive care units. The 2022 Guidelines developed by the American College of Cardiology, the American Heart Association, the Heart Failure Society of America, and the 2021 European Society of Cardiology Guidelines for the Diagnosis and treatment of acute and chronic heart failure, provide recommendations to manage decompensated patients in the intensive care unit (ICU). The first recommendation addresses the identification of the patient at admission, early diagnosis, and classification, to provide adequate treatment according to their needs. The second one is the initial assessment and stabilization to gather information required to identify Nursing Diagnoses and subsequent to Care Plan. Monitoring vital signs, hemodynamic parameters, and fluid balance must be included in this step. The third recommendation includes pharmacological and non-pharmacological management to improve myocardial contractility, optimize renal function, and continue previous therapy in addition to Nursing Interventions for symptom management such as oxygen therapy, position, and pain management. In severe cases, the preparation of the equipment for ventricular assistive devices, mechanical circulatory support, ultrafiltration, and dialysis may be required. The fourth recommendation consists of prevention of complications and rehospitalization. Nurses play a pivotal role in providing patient and family education either at the hospital or during outpatient visits. Education should focus on the recognition of early signs of heart failure, medication adherence, dietary modifications, physical activity, and psychosocial support. Nurses play a key role in supporting patients with heart failure at all stages. To provide evidence-based care, nurses must be familiar with guideline recommendations. In addition, nurses are able to contribute to the multidisciplinary team, delivering unique patient cantered care; and in doing so, critical care nurses contribute to patient survival and recovery. Patient and family support and education, help the patients to seek medical care early to avoid further hospital readmission.
Copyright (c) 2024 Paola Chauca Chipa, RN https://creativecommons.org/licenses/by-nc/4.0
Interrater Reliability of the COMHON Index To Assess Pressure Injury Risk In ICU
Background: When using a pressure injury risk assessment tool, it is important to consider its interrater reliability (IRR), given that multiple raters may assess individual patients using the tool. For repeated measurements on a scale, intraclass correlation (ICC) is the most appropriate method to assess reliability (de Vet et al., 2006; Streiner & Kottner, 2014). Aim: To summarise studies that have investigated interrater reliability of the COMHON Index using ICC. Methods: Interrater reliability studies. Results: Three studies have investigated interrater reliability (Fulbrook & Anderson, 2016; Uslu et al., 2024; Lovegrove et al., 2024) using English, Turkish and Chinese versions of the COMHON Index (https://wfccn.org/comhon-index). In the first study, ICC (2,1) .90 (95% CI .83-.95) was reported, and the COMHON Index was found to be superior to the Braden, Norton and Waterlow tools. In the two recent studies, ICC (1,1) .996 (95% CI .993-.998) and ICC (1,1) .973 (95% CI .949-.988). In the latter study, the COMHON Index was found to be superior to the Braden Scale. Conclusions: The COMHON Index has demonstrated excellent inter-rater reliability in three studies. Measurement error of the COMHON RAS is small, and therefore it is sufficiently sensitive to detect minimally important changes in score. Further research needed to test the predictive validity of the COMHON Index. References de Vet HC, Terwee CB, Knol DL, Bouter LM. When to use agreement versus reliability measures. Journal of Clinical Epidemiology. 2006;59(10):1033–1039. https://doi.org/10.1016/j.jclinepi.2005.10.015. Fulbrook P, Anderson A. Pressure injury risk assessment in intensive care: comparison of inter-rater reliability of the COMHON (Conscious level, Mobility, Haemodynamics, Oxygenation, Nutrition) Index with three scales. Journal of Advanced Nursing. 2016;72(3):680-692. https://doi.org/10.1111/jan.12825. Lovegrove J, Fulbrook P, Yuan C, Lin F, Liu X-L The COMHON Index and the Braden Scale to assess pressure injury risk in intensive care: An interrater reliability and convergent validity study, 2024, unpublished. Streiner DL, Kottner J. Recommendations for reporting the results of studies of instrument and scale development and testing. Journal of Advanced Nursing. 2014;70(9):1970–1979. https://doi.org/10.1111/jan.12402. Uslu Y, Fulbrook P, Eren E, Lovegrove J, Cobos Vargas A, Colmenero M. Assessment of pressure injury risk in intensive care using the COMHON Index: an interrater reliability study. Intensive and Critical Care Nursing. 2024, (online ahead of print). https://doi.org/10.1016/j.iccn.2024.103653.
Copyright (c) 2024 Paul Fulbrook RN PhD https://creativecommons.org/licenses/by-nc/4.0
Unveiling the Hidden Strain: Exploring Second Victim Phenomenon among Critical Care Nurses
Background Critical care nurses work in a highly stressful and challenging environment that demands swift decisions in life-threatening situations. Moreover they are susceptible to experiencing emotional distress and psychological strain, particularly following adverse events or medical errors. This phenomenon, known as the second victim phenomenon, has garnered increasing attention in recent years due to its significant impact on healthcare provider’s well-being and the quality of patient care. It is estimated that approximately half of all healthcare providers experience its impact at least once during their professional career. If not addressed, second victims can face long-term career sequelae such as changing roles or leaving the chosen profession prematurely. Aim: The aim of the study was to identify the prevalence of second victim phenomenon among critical care nurses with a focus on understanding its underlying manifestations, and implications on nursing practice. Methods: A cross-sectional descriptive survey design was adopted. Non probability purposive sampling technique was used to recruit 108 critical care nurses. Standardised Second Victim Experience and Support Tool (SVEST), a self-reported semi structured questionnaire, was used and data was collected using Google form from critical care nurses across various multispecialty hospitals. Ethical considerations: The study obtained research ethics approval, and all participants were informed of the voluntary and anonymous nature of their participation. Results/Findings: The study findings indicate that a majority (65%) of nurses had ICU experience of 5 years and above, with the remaining 35% having 1-5 years of experience. Notably, 68% of nurses reported experiencing second victim syndrome, with prevalent symptoms including guilt (78%), anxiety (53%), self-directed anger (25%), and reduced self-confidence (78%) following unanticipated errors or near-miss events. Also 35% of nurses reported physical distress, 20% reported absenteeism post event, 9% of them showed turnover intention. Second victims also reported support systems as an imperative part of the recovery process after an adverse event occurs, especially through peer support, emotional support, and informational support. Conclusion: In conclusion, the study underscores the significant impact of second victim syndrome on critical care nurses, with a notable proportion reporting its occurrence and the need for targeted interventions and second victim support programs to promote the well-being of nurses in high-stress environments. Through “YOU Matter” Program during induction period novice nurses must be made aware of the support system available to promote wellbeing of nurses.
Copyright (c) 2024 Jaya Kuruvilla RN PhD https://creativecommons.org/licenses/by-nc/4.0
Neurological Complications of Cancer and Immunocompromised patients
Introduction: Cancer is a leading cause of disability and death throughout the world. In the United States, 1 in 4 deaths are due to cancer, making it the second leading cause of death. A large percentage of the cancer population developed a neurologic complication of their disease. Up to 25% of cancer patients develop a central nervous system (CNS) metastasis over the course of their illness. Because patients are living longer after their cancer diagnosis, the number of neurologic complications has increased, and more patients are suffering from the late effects of treatment and the disease itself. Discussion: Direct Effects of Cancer on the Nervous System: Brain and all CNS metastases typically occur late in the cancer course. In autopsy studies, it has been shown consistently that about 30% of individuals with breast cancer have CNS metastases. The rate is even higher for lung cancer and melanoma at 34 and 72%, respectively. Approximately 25% of all patients with cancer have CNS metastases at death, and in approximately 40% of these patients, the brain is the sole metastatic site. Indirect Effects of Cancer on the Nervous System: While neurologic complications of cancer can develop, a consequence of direct metastases to the nervous system, cancer also affects the nervous system indirectly. Cancer induces an inflammatory state, and certain tumors secrete procoagulant substances. For these reasons, patients with cancer, particularly adenocarcinomas, are at a higher risk for ischemic stroke, accounting for the 14.6% incidence of cerebrovascular disease found in an autopsy study. In addition, population studies also show a higher risk of intracerebral haemorrhage. Primary and secondary brain tumors may haemorrhage; particularly high-risk tumors are oligodendrogliomas and brain metastases from choriocarcinoma, melanoma, or renal cell carcinoma. Alternatively, cancer can lead to spontaneous intraparenchymal hemorrhage by causing coagulopathy, as in acute promyelocytic leukemia (APL), patients usually have disseminated intravascular coagulation (DIC) at presentation. Complications of Cancer Treatment: Another category of neurologic dysfunction is the short- and long-term effects of cancer therapies, such as radiotherapy, chemotherapy, and the many procedures that are prescribed. Patients receiving treatment are susceptible to a wide variety of pathogens and often develop more severe disease than is seen in the general population from the same infectious agent. Activating the immune system can also have significant neurologic toxicity, as well as treatment-related neurotoxicity can also occur following radiotherapy and surgery. These treatments place patients at risk for stroke, radiation necrosis and other forms of direct damage to nearby structures, such as the brachial plexus. Conclusion: The nervous system is both a uniquely protected and uniquely vulnerable organ system. Neurologic complications of cancer are common and increasingly prevalent, as patients are surviving longer; they might experience both the acute and delayed consequences of the disease and its treatment. Compromise of the nervous system by cancer or its therapy is often serious but frequently treatable, particularly if recognized early before serious deficits are fully established, making accurate diagnosis essential.
Copyright (c) 2024 Ayoub Abu Alrobe, RN https://creativecommons.org/licenses/by-nc/4.0
Background: Sepsis is a medical emergency that requires immediate assessment and management. Sepsis can affect patients at any age group which increases the number of sepsis cases. The utilization of advanced diagnostic technologies and the implementation of best practice guidelines led to an increase in the number of sepsis survivors. Yet, those who survive sepsis suffer from post-sepsis syndrome after hospital discharge. This syndrome involves deficits in multiple systems, including immune, cognitive, psychiatric, cardiovascular, and renal system changes. These changes have a determinantal effect on sepsis survivors leading to fatigue, pain, visual disturbances, gastrointestinal problems, and neuropsychiatric problems. The aim of this paper is to shed light onto the neurological changes after sepsis. Methods: A literature review on neurological complications post sepsis was conducted. Literature review findings were presented in a lecture format, starting with a case discussion to guide the audience’s attention to the neurological complications associated with sepsis. How these complications manifest among sepsis survivors and what are the most common forms of neurological complications post sepsis. As well as the impact of these neurological changes on the quality of life for sepsis survivors. Result: The literature review revealed that patients who survive sepsis suffer from various cognitive disturbances such as Sepsis Associated Delirium (SAD) in 53% of the cases. The neurological symptoms in SAD range from agitation, hallucinations, lack of focus, disturbance of the sleep–wake-cycle, and coma. 37% of patients with sepsis recover from neurological symptoms within four weeks after the initial onset. Sepsis Associated Encephalopathy (SAE) is another common form of neurological changes post sepsis that occurs due to changes in cerebral perfusion with exclusion of central nervous system infection, structural brain injury, and metabolic causes. SAE is caused by inflammation that increases endothelial permeability of the blood-brain-barrier, leading to hypoxia, imbalance of neurotransmitters, glial activation causing axonal and neuronal loss. In addition, depressive symptoms were found in 28% of sepsis survivors. Another study included in this review showed that age is a serious risk factor for developing cognitive impairment post sepsis. Patients at the age of 65 years and older who survive sepsis are at 10-fold increase the incidence rate of cognitive impairment. The most common form of cognitive impairment is disturbance of memory and dementia. A prospective observational study that assessed the quality-of-life post sepsis indicated 60% of patients who survived sepsis had difficulties in normal activities, and 56% had pain. Conclusion: Sepsis is common and is associated with various neurological sequel affecting cognitive and physical functions of sepsis survivors. Neurological complications post sepsis may persist for months or years after patients’ recovery. To effectively manage those patients, it is pivotal to investigate and eliminate the possibility of a primary central nervous system pathology that might cause neurological alterations. Regular screening of sepsis survivors on symptoms of depression, chronic pain and post-traumatic stress within one year after ICU should be considered.
Evolving Evidence Practices in Acute Stroke Care
Acute ischemic stroke care is experiencing a transformative shift, driven by emerging evidence supporting optimized thrombolytic strategies, extended treatment windows, and advanced imaging protocols. Recent clinical trials have demonstrated the non-inferiority—and, in certain aspects, superiority—of tenecteplase over alteplase. With its simplified single bolus administration, enhanced fibrin specificity, and potential for improved recanalization rates, tenecteplase is increasingly recognized as a preferred first-line thrombolytic agent in many treatment algorithms. Additionally, streamlined treatment protocols have contributed to reduced door-in and door-out times for patients requiring transfer to higher-level centers for endovascular stroke interventions. The conventional 4.5-hour thrombolysis window is also being redefined. Advanced imaging techniques, such as CT perfusion and diffusion-weighted MRI, now enable the identification of salvageable brain tissue beyond standard time constraints. These technologies have facilitated the safe and effective administration of thrombolytics in carefully selected patients, extending the treatment window to as much as 9 hours post-symptom onset. Wake-up stroke, historically excluded from thrombolytic treatment due to uncertainty around symptom onset time, is now being successfully addressed through imaging-based protocols. Landmark trials, including WAKE-UP and EXTEND, have demonstrated the efficacy and safety of IV thrombolysis in patients showing imaging evidence of salvageable brain tissue, even without a known onset time. Further advancements include the integration of innovative tools, such as electronic fundoscopy, which has improved the timely detection and management of central retinal artery occlusion, ensuring faster intervention and better outcomes for these high-risk patients. Despite these significant advancements, challenges persist in translating evidence into practice. Barriers such as equitable access to advanced imaging, variability in protocol adoption, and healthcare system preparedness continue to impact stroke care delivery. This presentation will synthesize the latest evidence, share clinical insights, and outline practical strategies derived from the experience of an integrated healthcare system in Northern California, comprising 21 stroke centers. Key focus areas include the adoption of tenecteplase over alteplase, leveraging tele-stroke technology for real-time acute care consultation, extending thrombolysis treatment windows, implementing electronic fundoscopy, and optimizing wake-up stroke management protocols.
Copyright (c) 2024 Patricia A. Zrelak, PhD, RN, NEA-BC, ASC-BC, SCRN, CNRN, CCRN, PHN, FAHA https://creativecommons.org/licenses/by-nc/4.0
The Immeasurable Impact of a Community of Practice
Copyright (c) 2024 Prof. Ged Williams, AO, Kathleen Vollman, RN, MSN, RN, CCNS, FCCM, FCNS, FAAN https://creativecommons.org/licenses/by-nc/4.0