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This paper begins with the lived accounts of emergency and critical care medical interventions in which an unhoused person is brought to the emergency department in cardiac arrest. The case is a dramatised representation of the extent to which biopolitical forces via reduction to bare life through biopolitical and necropolitical operations are prominent influences in nursing and medical care. This paper draws on the scholarship of Michel Foucault, Giorgio Agamben, and Achille Mbembe to offer a theoretical analysis of the power dynamics that influence the health care and death care of patients who are caught in the auspices of a neoliberal capitalist healthcare apparatus. This paper offers analysis of the overt displays of biopower over those individuals cast aside as generally unworthy of access to healthcare in a postcolonial capitalist system, in addition to the ways in which humans are reduced to 'bare life' in their dying days. We analyse this case study through Agamben's description of thanatopolitics, a 'regime of death', and the technologies that accompany the dying process, particularly in that of the homo sacer. Additionally, this paper illustrates the ways in which necropolitics and biopower are integral to understanding how the most advanced and expensive medical interventions make visible the political values of the healthcare system and how nurses and healthcare functions in these deathworlds. The purpose of this paper is to develop a greater understanding of biopolitical and necropolitical operations in acute and critical care environments, and to offer guidance to nurses in these spaces as they work to uphold ethical duties in a system that increasingly dehumanises. [ABSTRACT FROM AUTHOR]

In the fall of 1997 George D. Lundberg and John E. Wennberg wrote an editorial in JAMA calling for comprehensive quality improvement programs to become the driver of the American health care system. The suggestion came during the Second European Forum on Quality Improvement in Health Care held in Paris, France, in April 1997 and was based on comments made by Donald Berwick. The concept was to focus on an organized response to problem identification and proposed solutions to improve patient care and protect the health of the public. Critical care medicine represents a large segment of health care and is undergoing dramatic changes during our managed care revolution. General ICU severity of illness models have been developed, tested, and shown to provide a useful estimate of hospital mortality for populations of critically ill patients. These systems have captured the imagination of clinical researchers and have become an integral component of a large number of publications as well as a part of many ICU databases. These risk adjustment severity models are remarkably robust for heterogeneous patient populations but the models have not been shown to validate well in new settings. We feel that by focusing on the episode of critical illness rather than each individual ICU admission and by going beyond the traditional acute hospital discharge to determine whether the patient lives or dies, we can better evaluate critical care system performance and cost-effectiveness. The incentives for high quality/low cost should favor integrated comprehensive critical care delivery systems. Programs that score well should be identified as high quality and be honored as medallion level 1 ICUs. We challenge national and international critical care societies to evaluate and then debate the described definitions and recommendations as a call to action. [ABSTRACT FROM AUTHOR]

Aims: Individuals with Limited English Proficiency (LEP) represent a growing percentage of the U.S. population yet face inequities in health outcomes and barriers to routine care. Despite these disparities, LEP populations are often excluded from clinical research studies. The aim of this study was to assess for the inclusion of LEP populations in published acute care stroke research in the U.S. Methods: A systematic review was conducted of publications from three databases using acute care and stroke specific Medical Subject Heading key terms. The primary outcome was whether language was used as inclusion or exclusion criteria for study participation and the secondary outcome was whether the study explored outcomes by language. Results: A total of 167 studies were included. Twenty-two studies (13.2%) indicated the use of language as inclusion/exclusion criteria within the manuscript or dataset/registry and only 17 studies (10.2%) explicitly included LEP patients either in the study or dataset/registry. Only four papers (2%) include language as a primary variable. Conclusions: As LEP populations are not routinely incorporated in acute care stroke research, it is critical that researchers engage in language-inclusive research practices to ensure all patients are equitably represented in research studies and ultimately evidence-based practices. [ABSTRACT FROM AUTHOR]

Background: Pediatric traumatic brain injury (TBI) affects about 475,000 children in the United States annually. Studies from the 1990s showed worse mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC), but did not examine mild pediatric TBI. Evidence-based guidelines used to identify children with clinically insignificant TBI who do not require head CT were developed by the Pediatric Emergency Care Applied Research Network (PECARN). However, which patients can be safely observed at a non-PTC is not directly addressed.Methods: A systematic review of the literature was conducted, focusing on management of pediatric TBI and transfer decisions from 1990 to 2020.Results: Pediatric TBI patients make up a great majority of preventable transfers and admissions, and comprise a significant portion of avoidable costs to the health care system. Majority of mild TBI patients admitted to a PTC following transfer do not require ICU care, surgical intervention, or additional imaging. Studies have shown that as high as 83% of mild pediatric TBI patients are discharged within 24 hrs.Conclusions: An evidence-based clinical practice algorithm was derived through synthesis of the data reviewed to guide transfer decision. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the following criteria: blunt, no concern for NAT, low risk on PECARN assessment, or intermediate risk on PECARN with negative imaging or imaging with either isolated, nondisplaced skull fractures without ICH and/or EDH, or SDH <0.3 cm with no midline shift. [ABSTRACT FROM AUTHOR]

Objectives: The Society of Critical Care Medicine convened its Academic Leaders in Critical Care Medicine taskforce on February 22, 2016, during the 45th Critical Care Congress to develop a series of consensus papers with toolkits for advancing critical care organizations in North America. The goal of this article is to propose a framework based on the expert opinions of critical care organization leaders and their responses to a survey, for current and future critical care organizations, and their leadership in the health system to design and implement successful regionalization for critical care in their regions.Data Sources and Study Selection: Members of the workgroup convened monthly via teleconference with the following objectives: to 1) develop and analyze a regionalization survey tool for 23 identified critical care organizations in the United States, 2) assemble relevant medical literature accessed using Medline search, 3) use a consensus of expert opinions to propose the framework, and 4) create groups to write the subsections and assemble the final product.Data Extraction and Synthesis: The most prevalent challenges for regionalization in critical care organizations remain a lack of a strong central authority to regulate and manage the system as well as a lack of necessary infrastructure, as described more than a decade ago. We provide a framework and outline a nontechnical approach that the health system and their critical care medicine leadership can adopt after considering their own structure, complexity, business operations, culture, and the relationships among their individual hospitals. Transforming the current state of regionalization into a coordinated, accountable system requires a critical assessment of administrative and clinical challenges and barriers. Systems thinking, business planning and control, and essential infrastructure development are critical for assisting critical care organizations.Conclusions: Under the value-based paradigm, the goals are operational efficiency and patient outcomes. Health systems that can align strategy and operations to assist the referral hospitals with implementing regionalization will be better positioned to regionalize critical care effectively. [ABSTRACT FROM AUTHOR]

For the past 25 years, the San Antonio Uniformed Services Health Education Consortium (SAUSHEC) Emergency Medicine Residency has used an end-of-shift evaluation (ESE) to provide formative feedback and assess resident progress. The instrument has evolved from a simple half-sheet of paper to a more complex electronic milestones assessment. The length and detail of the evaluation form has grown appreciably, but the precise impact of these changes on the effectiveness of formative feedback unknown. The authors present a narrative description of the evolution of this instrument in response to changing requirements and efforts to optimize its utility. Our experiences over the past quarter-century are presented in the context of now-common utilization of similar evaluation tools among emergency medicine (EM) training programs. The evolution of our ESE instrument may be of historical interest to EM educators and provide examples for those seeking to develop or adapt their own evaluation tools. [ABSTRACT FROM AUTHOR]

Objective: To describe the monthly variation in the prevalence and patterns of unfinished nursing care and to determine the relationships between the system of nursing care and unfinished nursing care at the US Army Burn Center.Methods: This was a repeated measures, descriptive study. For one week per month for six months, all nurses providing direct patient care on two inpatient burn units (intensive care and progressive care) were asked to complete an anonymous paper survey, which contained the Perceived Implicit Rationing of Nursing Care instrument, to estimate the prevalence of unfinished nursing care on their unit. Unit administrative data also were collected from the unit nursing leaders each month. Descriptive statistics and multilevel modeling were used in the analysis.Results: Most (80.5%) eligible nurses participated at least once; 46.6% participated three or more times. A high proportion (85.7-100%) of nurses left at least one element of care unfinished; the mean number of activities left unfinished over each 7 shift period per nurse was 16.2. Only nursing care hours provided by float staff significantly predicted nurse estimates of unfinished nursing care, β=.008, SE=.001, p<.05.Conclusions: The prevalence of unfinished nursing care at the US Army Burn Center was high and generally consistent with other studies of unfinished nursing care in non-burn settings. The inability to meet the demand for nursing care, as evidenced by the presence of unfinished nursing care, may be the result of a limited surge capacity. Implications for research, policy, and practice were discussed. [ABSTRACT FROM AUTHOR]

Aim: The aim of this paper was to increase international collaboration on end of life care (EoLC) in critical care. Objectives included highlighting key challenges for critical care nurses in EoLC through a transcribed interview between a clinician, an educationalist and a researcher who all hold an EoLC focus. Background: EoLC continues to hold high profile within international health care arenas, including critical care units. Whilst end of life care remains well debated, it still presents many challenges for everyday practitioners. Dialogue with international colleagues and disciplines may provide opportunity for further understanding of this complex and sensitive area. Conclusions: A key issues to arise from this venture of shared learning was that futility of treatment is problematic for all. This is further complicated in the USA where the concept of (family) autonomy strongly shapes EoLC decision making. Relevance to clinical practice: This paper demonstrates that there are opportunities for nurses within health care teams which could be addressed through education and professional development initiatives. Furthermore, knowledge from other disciplines can provide a useful lens through which to improve our understanding of EoLC. [ABSTRACT FROM AUTHOR]

Violence in the acute care psychiatric setting is an ongoing serious problem. Maintenance of a safe therapeutic environment is a paramount responsibility of nurses practicing in this area. Ethical and legal standards demand that the nurse intervenes in aggressive situations in a manner that employs the least intrusive and restrictive measures necessary to provide safety. Therefore, accurate and effective decision-making in aggressive situations, which can escalate rapidly, is of great importance. This paper discusses a theoretical model for decision-making in selecting interventions with aggressive psychiatric patients. This model may provide a basis for the development of training and education programs for effective decision-making in this area. [ABSTRACT FROM AUTHOR]

This article presents emerging findings from the first year of a two-year study, which employed ethnographic methods to explore the culture of interprofessional collaboration (IPC) and family member involvement in eight North American intensive care units (ICUs). The study utilized a comparative ethnographic approach - gathering observation, interview and documentary data relating to the behaviors and attitudes of healthcare providers and family members across several sites. In total, 504 hours of ICU-based observational data were gathered over a 12-month period in four ICUs based in two US cities. In addition, 56 semi-structured interviews were undertaken with a range of ICU staff (e.g. nurses, doctors and pharmacists) and family members. Documentary data (e.g. clinical guidelines and unit policies) were also collected to help develop an insight into how the different sites engaged organizationally with IPC and family member involvement. Directed content analysis enabled the identification and categorization of major themes within the data. An interprofessional conceptual framework was utilized to help frame the coding for the analysis. The preliminary findings presented in this paper illuminate a number of issues related to the nature of IPC and family member involvement within an ICU context. These findings are discussed in relation to the wider interprofessional and health services literature. [ABSTRACT FROM AUTHOR]

A growing body of literature suggests that face-to-face interaction among clinicians in hospitals affects patient outcomes. How can face-to-face interaction among clinicians be influenced positively to improve patient outcomes in hospitals? So far, most strategies for improving face-to-face interaction in hospitals have focused on changing organizational culture. In contrast, this paper proposes a theoretical model that shows how spatial program and structure can help face-to-face interaction fulfill its purposes in hospitals by controlling the interfaces among different communities of clinicians. [ABSTRACT FROM AUTHOR]

BACKGROUND: Tradition has led us to believe that a heavily sedated patient is a comfortable, settled, compliant patient for whom sedation will improve outcome. The current move witnessed in clinical practice today of limiting sedation has led health care in recent years to question the benefit and necessity of routine, continuous sedation for all patients requiring mechanical ventilation. However, as a result there has been a rise in the amount of agitation being reported as being experienced by patients with the daily withdrawal of sedation. AIMS: The purpose of this paper is to review current arguments for and against perserving with agitation versus re-sedating, when it presents during the daily sedation breaks. FINDINGS: Of the literature reviewed, the question to re-sedate the mechanically ventilated agitated patient during sedation breaks remains an issue of contention. Although there is evidence focusing on the psychological effects of long-term sedation and sedation breaks specifically, the complex nature of critical illness in some cases means that individualized care is of paramount importance and in-depth assessment is crucial when deciding to re-sedate in the face of undetermined agitation. Agitation has been closely linked with several incidents that can be detrimental to patient safety, such as removal of lines and unplanned self-extubation. CONCLUSION: The recommendations of this review are that nurses should re-commence sedation if the patient becomes agitated following a sedation break. [ABSTRACT FROM AUTHOR]

Historically, African Americans have not been well represented in hospice care. African Americans make up approximately 12 percent of the general population, but according to the National Hospice and Palliative Care Organization, in the year 2002, African Americans constituted only 8 percent of the more than 600,000 Americans who died while receiving hospice care. As diversity increases in the United States, cultural misunderstandings and differences emerge around end-of-life care. This paper will focus on African Americans' underuse of hospice services. First, the author considers the increased need for communication and cross-cultural understanding. Second, the author discusses African American challenges and concerns that may result from cultural differences, values, spirituality, beliefs, and trust. Third, the hospice experiences of two African American families are presented. Finally, the author raises the question: What is needed to support and assist the African American community in utilizing hospice interventions? [ABSTRACT FROM AUTHOR]

Purpose: Children with hypoplastic left heart syndrome (HLHS) experience numerous vulnerabilities during transitions from hospital to home during their first year of life. This paper examines the parents' responses to the situations they experience during the initial interstage transition as described through illness blogs. Design and methods: A qualitative descriptive design through inductive theme development using thematic analysis was performed for this study. Text data were used from publically available blogs written by parents of HLHS children on their feelings and experiences during transitions between hospital‐ and home‐care during the interstage period. Results: Six blogs were analyzed. Overall, the lack of difference in normalcy for these parents and their families was apparent. Major themes included: thoughts and feelings when discharged from the hospital, difficulties with hospital readmissions, protecting their child from infection, and developing a support system. Conclusions: Parents looked forward to going home and learned all they could about properly caring for their child before going home. They were disappointed and frustrated when returning to the hospital for either emergency or scheduled admissions and were not prepared to see their child in the intensive care unit environment again. Many parents isolated themselves and avoided the hospital as much as possible to avoid their child developing an infection. All parents had support systems through family and/or friends and found an unexpected sense of support through their blog families. [ABSTRACT FROM AUTHOR]