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The article discusses research addressing the challenges of hospitals in the future. It references a study by the U.S. Joint Commission, available at www.jointcommission.com. These challenges include older and sicker patients, patient safety and quality of care, economics, and the work force, and offering guiding principles and actions.

Clinical Relevance Clostridioides (formerly Clostridium) difficile infection is among the most identified causes of health care--associated infections in US hospitals and remains a major public health problem. The incidence and severity of C difficile infection are high among critically ill patients. Treating critically ill patients is challenging; treatment failure is especially common because of comorbidities and the continued need for antibiotic therapy for other infections. Because of the high risk of C difficile infection recurrence and high mortality rate associated with the disease, intensive research has taken place over the last decade to improve patient outcomes. This research has resulted in new drugs indicated for C difficile infection and new information on existing drugs. The 2010 clinical practice guidelines for C difficile infections have been updated on the basis of this new information. Purpose of Paper To review the 2017 update of the clinical practice guidelines from the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America. Content Covered The updated recommendations for the treatment of C difficile infection, the clinical pharmacology of old and new drugs for treating the infection, and the role of critical care nurses in minimizing the risk of C difficile infection for their patients. [ABSTRACT FROM AUTHOR]

Background: Iatrogenic malnutrition is a significant burden to patients, clinicians, and health care systems. Compared with well-nourished patients, underfed patients (those who receive less than 80% of their daily energy requirement) have more adverse outcomes related to nutritional status. Volume-based protocols allow for catch-up titrations, are consistently superior to rate-based protocols, and can be implemented in most settings. Local Problem: This project was conducted in an 8-bed neuroscience intensive care unit in which up to 41% of patients who required enteral feeding were underfed. Methods: This quality improvement clinical practice change project used a before-and-after design to evaluate (1) the effect of implementing a volume-based feeding protocol on the delivery of enteral feeds and (2) the effect of a nutrition-based project on staff members' attitudes regarding nutrition in critical care. The effectiveness of a volume-based feeding titration protocol was compared with that of a rate-based feeding protocol for achieving delivery of at least 80% of prescribed nutrition per 24-hour period. Staff members' attitudes were assessed using a survey before and after the project. Results: During 241 enteral feeding days (n = 40 patients), the percentage of delivered enteral feeding volume and the percentage of days patients received at least 80% of the prescribed volume increased after volume-based feeding was implemented. After project implementation, 74 staff members reported increased emphasis on nutrition delivery in their practice and a higher level of agreement that nutrition is a priority when caring for critically ill patients. Conclusions: Using a volume-based feeding protocol with supplemental staff education resulted in improved delivery of prescribed enteral feeding. [ABSTRACT FROM AUTHOR]

Background Although most critically ill patients experience at least 1 blind insertion of a feeding tube during their stay in an intensive care unit, little is known about the types of health care personnel who perform these insertions or about methods used to determine proper positioning of the tubes. Objectives To describe results from a national survey of critical care nurses about feeding tube practices in their adult intensive care units. The questions asked included who performs blind insertions of feeding tubes and what methods are used to determine if the tubes are properly positioned. Methods Data were collected from members of the American Association of Critical-Care Nurses via pencil-and-paper and online surveys. Results from both forms were combined for data analysis and were compared with practice recommendations of national-level organizations. Results A total of 2298 responses were obtained. Physicians perform more blind insertions of styleted feeding tubes than do nurses; in contrast, nurses place more nonstyleted tubes. Radiographic confirmation of correct position is mandated more often for blindly inserted styleted tubes (92.3%) than for nonstyleted tubes (57.5%). The 3 most commonly used bedside methods to determine tube location are auscultation for air injected via the tube, appearance of feeding tube aspirate, and observation for indications of respiratory distress. Conclusions Recommendations from multiple national-level organizations to obtain radiographic confirmation that each blindly inserted feeding tube is correctly positioned before the first use of the tube are not adequately implemented. Auscultation is widely used despite recommendations to the contrary. [ABSTRACT FROM AUTHOR]

Background: Evidence-based research indicates that subjective questionnaires should be eliminated in screening for alcohol use disorder and management of alcohol withdrawal syndrome in critical care patients. However, transitioning clinicians away from these screening tools remains challenging. Objective: To improve screening for alcohol use disorder and management of alcohol withdrawal syndrome in the critical care setting by implementing an evidence-based alcohol use disorder screening tool and alcohol withdrawal syndrome protocol for critical care patients. Methods: The project site was a 17-bed adult medical intensive care unit in a large, southeastern US teaching hospital. Interventions consisted of the elimination of previously used tools such as the Clinical Institute Withdrawal Assessment for Alcohol–Revised and implementation of the Prediction of Alcohol Withdrawal Severity Scale for alcohol use disorder screening and the Richmond Agitation-Sedation Scale and symptom-triggered benzodiazepine administration for alcohol withdrawal syndrome management. Results: Alcohol use disorder screening among the critical care patient population increased by 49% from before to after the intervention. Of the patients at risk for withdrawal, 79% had an order for monitoring with the new intensive care unit alcohol withdrawal protocol in the postintervention group, compared with 35% who had an order for monitoring with the Clinical Institute Withdrawal Assessment for Alcohol–Revised in the preintervention group. Conclusion: The elimination of previously used tools and the implementation of the Prediction of Alcohol Withdrawal Severity Scale and the new intensive care unit alcohol withdrawal protocol improved alcohol use disorder screening and alcohol withdrawal syndrome management among critical care patients. [ABSTRACT FROM AUTHOR]

The author discusses the need for critical care nurses to read beyond the headlines to examine the quality that exists for their support. Topics include ethics and professionalism in the medical sector, sensationalism in medical headlines, and medical errors. Also mentioned are fear-mongering and scary health care statistics.

Background: Confusion about how to assess for intolerance to feedings often results in unnecessary feeding interruptions. Objectives: To report findings from a national survey of methods used by critical care nurses to assess tolerance to gastric tube feedings and to discuss the findings in light of current enteral nutrition guidelines. Methods: A paper-and-pencil survey was mailed to 1909 members of the American Association of Critical-Care Nurses. In addition, the same survey was posted online in a newsletter circulated to association members. Results from both surveys were pooled for data analysis. Results: A total of 2298 responses were obtained; most respondents reported using a combination of methods to assess tolerance to gastric tube feedings (listening for bowel sounds, measuring gastric residual volumes, observing for abdominal distention/discomfort and for nausea and vomiting). More than 97% of the nurses reported measuring gastric residual volumes; the most frequently cited threshold levels for interrupting feedings were 200 mL and 250 mL. About 25% of the nurses reported interrupting feedings for gastric residual volumes of 150 mL or less; only 12.6% of the respondents reported allowing gastric residual volumes of up to 500 mL before interrupting feedings. Conclusions: Practice among the 2298 critical care nurses varied widely. Many of the survey respondents are practicing in ways that can unnecessarily diminish the delivery of calories to patients. Protocols based on current enteral nutrition guidelines must be developed and implemented in practice settings. [ABSTRACT FROM AUTHOR]

Reports on the revamping of the courses entitled "Critical Care Nursing I," and "Critical Care Nursing II," at Marymount University in Arlington, Virginia, to include the American Association of Critical-Care Nurses Synergy Model for Patient Care. Information on the university's program of study; Comparisons between both courses; Information on the 8 nurse dimensions of the Synergy Model.

Background: Safe, reliable, high-quality critical care delivery depends upon interprofessional teamwork. Objective: To describe perceptions of intensive care unit (ICU) teamwork and healthy work environments and evaluate whether perceptions vary by profession. Methods: In August 2015, Assessment of Interprofessional Team Collaboration Scale (AITCS) and the American Association of Critical-Care Nurses Healthy Work Environment Assessment Tool (HWEAT) surveys were distributed to all interprofessional members at the 68 ICUs participating in the ICU Liberation Collaborative. Overall scores range from 1 (needs improvement) to 5 (excellent). Results: Most of the 3586 surveys completed were from registered nurses (51.2%), followed by respiratory therapists (17.8%), attending physicians (10.5%), rehabilitation therapists (8.3%), pharmacists (4.9%), nursing assistants (3.1%), and physician trainees (4.1%). Overall, respondents rated teamwork and work environment health favorably (mean [SD] scores: AITCS, 3.92 [0.64]; HWEAT, 3.45 [0.79]). The highest-rated AITCS domain was "partnership/shared decision-making" (mean [SD], 4.00 [0.63); lowest, "coordination" (3.67 [0.80]). The highest-scoring HWEAT standard was "effective decision-making" (mean [SD], 3.60 [0.79]); lowest, "meaningful recognition" (3.30 [0.92]). Compared with attending physicians (mean [SD] scores: AITCS, 3.99 [0.54]; HWEAT, 3.48 [0.70]), AITCS scores were lower for registered nurses (3.91 [0.62]), respiratory therapists (3.86 [0.76]), rehabilitation therapists (3.84 [0.65]), and pharmacists (3.83 [0.55]), and HWEAT scores were lower for respiratory therapists (3.38 [0.86]) (all P ≤.05). Conclusions: Teamwork and work environment health were rated by ICU team members as good but not excellent. Care coordination and meaningful recognition can be improved. [ABSTRACT FROM AUTHOR]

Background: Losing a loved one in the intensive care unit is associated with complicated grief and increased psychologic distress for families. Providing bereavement support may help families during this time. However, little is known about the bereavement experiences of families of patients in the cardiac intensive care unit. Objective: To describe the bereavement experiences of families of patients in the cardiac intensive care unit. Methods: In this secondary analysis, an exploratory, descriptive design was used to understand the families' bereavement experiences. Families from 1 cardiac intensive care unit in a tertiary medical center in the western United States participated. Audiotaped telephone interviews were conducted by using a semistructured interview guide 13 to 15 months after the patient's death. A qualitative, descriptive technique was used for data analysis. Two independent researchers coded the interview transcripts and identified themes. Results: Twelve family members were interviewed. The majority were female (n = 8, 67%), spouses (n = 10, 83%), and White (n = 10, 83%); the mean age (SD) was 58.4 (16.7) years. Five main themes emerged: (1) families' bereavement work included both practical tasks and emotional processing; (2) families' bereavement experiences were individual; (3) these families were resilient and found their own resources and coping mechanisms; (4) the suddenness of a patient's death influenced families' bereavement experiences; and (5) families' experiences in the intensive care unit affected their bereavement. Conclusions: This study provided insight into the bereavement experiences of families of patients in the cardiac intensive care unit. These findings may be useful for professionals working with bereaved families and for cardiac intensive care units considering adding bereavement support. [ABSTRACT FROM AUTHOR]

Background: Although diaries are an evidence-based practice that improves the quality of life of patients in an intensive care unit and their loved ones, centers in the United States are struggling to successfully implement diary programs in intensive care units. Currently, few published recommendations address how to facilitate implementation of a diary program, and how to effectively sustain it, in an intensive care unit. Objectives: To discuss challenges with implementing diary programs in intensive care units at 2 institutions in the United States, and to identify solutions that were operationalized to overcome these perceived difficulties. Methods: The teams from the 2 institutions identified local barriers to implementing diaries in their intensive care units. Both groups developed standard operating procedures that outlined the execution and evaluation phases of their implementation projects. Results: Barriers to implementation include liability and patient privacy, diary program development, and implementation and sustainability concerns. Various strategies can help maintain clinical and family member engagement. Conclusion: Through a team's sustained dedication and a diligent assessment of perceived obstacles, a diary program can indeed be implemented within an intensive care unit. [ABSTRACT FROM AUTHOR]

Background: Provision of developmentally appropriate support for child visitors in adult intensive care units (ICUs) would benefit patients and young visitors. Research on best practices for child visitation in adult ICUs is limited. Objectives: To explore the perceptions and practices of nurses working in adult ICUs in the United States regarding child visitation and the role of child life specialists in this setting. Methods: Data were collected from 446 adult ICU nurses via a cross-sectional survey. The survey explored perceptions and practices regarding child visitation, access to child-friendly resources, and the feasibility of having a child life specialist in adult ICUs. Results: Several participants (303, 67.9%) felt that children were at risk for psychological trauma from visiting an adult ICU. Some participants (122, 27.4%) reported that their ICUs did not have policies for child visitation. Logistic regression showed that nurses with a master's degree were 1.8 times (P <.05) more likely to believe that young children (0-5 years) should visit. Nurses (105 of 197, 53.3%) were more likely to allow young children to visit if the patient was the child's parent or if the patient was dying. Child-friendly resources were not routinely available. Nurses expressed that adult ICUs could benefit from child life specialists facilitating child visitation. Conclusions: Nurses were inconsistently open to child visitation. Exceptions for older children (> 6 years), children whose parent was the patient, patients' illness severity, and end of life allowed more child visitation. Ways to facilitate child-friendly visitation in adult ICUs are discussed. [ABSTRACT FROM AUTHOR]

Background Pressure injuries, also known as pressure ulcers, are a serious complication of immobility. Patients should be thoroughly examined for pressure injuries when admitted to the intensive care unit to optimize treatment. Whether community-acquired pressure injuries correlate with poor hospital outcomes among critically ill patients is understudied. Objectives To determine whether pressure injuries present upon admission to the intensive care unit can serve as a predictive marker for longer hospitalization and increased mortality. Methods This study retrospectively analyzed admissions of adult patients to a 24-bed medical-surgical intensive care unit in a large level I trauma center in the northeast United States from 2010 to 2012. The association of pressure injuries with mortality and length of stay was assessed, using multivariable logistic regression and generalized linear models, adjusted for age, comorbidities, Acute Physiology and Chronic Health Evaluation III score, and other patient characteristics. Results Among 2723 patients, 180 (6.6%) had a pressure injury at admission. Patients with a pressure injury had longer mean unadjusted stay (15.6 vs 10.5 days; P <.001) and higher in-hospital mortality rate (32.2% vs 18.3%; P <.001) than did patients without a pressure injury at admission. After multivariable adjustment, pressure injuries were associated with a mean increase in length of stay of 3.1 days (95% CI 1.5-4.7; P <.001). Pressure injuries were not associated with mortality after adjusting for the Acute Physiology and Chronic Health Evaluation III score, but they may serve as a marker for increased risk of mortality if an Acute Physiology and Chronic Health Evaluation III score is unavailable. Conclusion Pressure injuries present at admission to the intensive care unit are an objective, easy-to-identify finding associated with longer stays. Pressure injuries might have a modest association with higher risk of mortality. [ABSTRACT FROM AUTHOR]

BACKGROUND Military nurses provide care to seriously injured service members in flight, on the ground, or at sea during transport from the point of injury to a facility capable of providing higher levels of care. From this experience nurses are at increased risk of developing negative behavioral health symptoms. Spirituality, a belief in someone or something greater than oneself, could provide behavioral health support for military nurses who serve in this role. OBJECTIVE To determine the impact of spirituality on the behavioral health of nurses who provided en route care while deployed to Iraq or Afghanistan. METHODS This exploratory mixed-methods study used 5 instruments to determine levels of anxiety, depression, posttraumatic stress, posttraumatic growth, and resilience among 119 military nurses. Interviews provided rich data about the experiences of these nurses and extended quantitative outcomes. RESULTS Posttraumatic Growth Inventory findings showed no significant change in spirituality based on deployment experiences (mean, 3.07; SD, 3.26). However, interviews revealed that spirituality served as a buffer against developing behavioral health issues. Many relied on spirituality to get them through difficult experiences. There was also a sense of moral injury as a few expressed regrets for things they witnessed or experienced. CONCLUSIONS Spirituality can insulate military nurses from negative behavioral health symptoms. Nurses included in the study relied on their spirituality to stay mentally fit. For nurses who experienced moral injury, supervisory recognition of this and appropriate referral may decrease the long-term effects of deployment on their behavioral health. [ABSTRACT FROM AUTHOR]

Caring for the critically ill does not occur solely in large medical centers or urban areas. Nurses practicing in rural or remote settings practice as nurse generalists, caring for a wide range of patients, including those needing critical care. As a nurse generalist, the need for a wide variety of skill sets challenges nurses in rural areas to maintain current practice through continuing education across many content areas. They also may not come in contact with critically ill patients or emergent situations as often as their urban counterparts, which can make remaining comfortable with more advanced skills difficult. Because nurses working in rural or remote areas may care for critically ill patients less often, the need to remain vigilant in pursuit of continuing education is increased; however, access to continuing education can be problematic because of geographic isolation, difficulty getting time off from work, limited financial resources, and perceived lack of applicable topics. With advances in technology, critical care nurses working in rural areas have more options for continuing education, which is crucial for maintaining a skilled nursing workforce in rural health care facilities. This article addresses challenges critical care nurses working in remote or rural areas face in pursuing continuing education and provides information about available educational opportunities. [ABSTRACT FROM AUTHOR]

Background Sudden speechlessness is common in critically ill patients who are intubated or have had surgery for head and neck cancer. Sudden inability to speak poses challenges for hospitalized patients because strategies to facilitate communication are often limited and unreliable. Objective To determine the impact of a technology-based communication intervention on patients' perception of communication difficulty, satisfaction with communication methods, and frustration with communication. Methods A quasi-experimental, 4-cohort (control and intervention) repeated-measures design was used. Data were collected daily for up to 10 days. Patients in adult critical care units were followed up as they were transferred to other units within the institutions selected for the study. The impact of a technology-based communication system (intervention) was compared with usual care (control). Patients' communication outcomes pertinent to communication with nursing staff that were evaluated included perception of communication ease, satisfaction with methods used for communication, and frustration with communication. Results Compared with participants in the control group, participants in the intervention group reported lower mean frustration levels (-2.68; SE, 0.17; 95% CI, -3.02 to -2.34; P<.001) and higher mean satisfaction levels (0.59; SE, 0.16; 95% CI, 0.27 to 0.91; P< .001) with use of the communication intervention. Participants in the intervention group reported a consistent increase in perception of communication ease during the hospital stay. Conclusions The results facilitated evaluation of a bedside technology-based communication intervention tailored to the needs of suddenly speechless critically ill patients. [ABSTRACT FROM AUTHOR]

BACKGROUND The health of critical care nurse work environments has been shown to affect patient care outcomes as well as the job satisfaction and retention of registered nurses. The American Association of Critical-Care Nurses (AACN) Critical Care Nurse Work Environment Survey was first conducted in 2006 following the release of the AACN Standards for Establishing and Sustaining a Healthy Work Environment and was conducted again in 2008. This article reports the results of the third AACN Critical Care Nurse Work Environment Survey conducted in 2013. OBJECTIVE To evaluate the current state of critical care nurse work environments. METHODS A total of 8444 AACN members and constituents responded to an online survey. RESULTS The overall health of critical care nurses’ work environments has declined since 2008, as have nurses’ perceptions of the quality of care. Respondents rated their overall work environment and factors associated with healthy work environments including quality of patient care, staffing, communication and collaboration, respect, physical and mental safety, moral distress, nursing leadership, support for certification and continuing education, meaningful recognition, job satisfaction, and career plans. Although some factors improved, declines in any factors are a concern. CONCLUSIONS An increasing body of evidence has shown relationships between healthy nurse work environments and patient outcomes. The results of this 2013 survey identified areas in which the health of critical care nurse work environments needs attention and care, requiring the relentless true collaboration of everyone involved. [ABSTRACT FROM AUTHOR]

Background Long-term acute care hospitals are an option for patients in intensive care units who require prolonged care after an acute illness. Predicting use of these facilities may help hospitals improve resource management, expenditures, and quality of care delivered in intensive care. Objective To develop a predictive tool for early identification of intensive care patients with increased probability of transfer to such a hospital. Methods Data on 1967 adults admitted to intensive care at a tertiary care hospital between January 2009 and June 2009 were retrospectively reviewed. The prediction model was developed by using multiple ordinal logistic regression. The model was internally validated via the bootstrapping technique and externally validated with a control cohort of 950 intensive care patients. Results Among the study group, 146 patients (7.4%) were discharged to long-term acute care hospitals and 1582 (80.4%) to home or other care facilities; 239 (12.2%) died in the intensive care unit. The final prediction algorithm showed good accuracy (bias-corrected concordance index, 0.825; 95% CI, 0.803-0.845), excellent calibration, and external validation (concordance index, 0.789; 95% CI, 0.754-0.824). Hypoalbuminemia was the greatest potential driver of increased likelihood of discharge to a long-term acute care hospital. Other important predictors were intensive care unit category, older age, extended hospital stay before admission to intensive care, severe pressure ulcers, admission source, and dependency on mechanical ventilation. Conclusions This new predictive tool can help estimate on the first day of admission to intensive care the likelihood of a patient's discharge to a long-term acute care hospital. [ABSTRACT FROM AUTHOR]

Background The number of devices with alarms has multiplied in recent years, causing alarm fatigue in bedside clinicians. Alarm fatigue is now recognized as a critical safety issue. Objective To determine if attitudes and practices related to clinical alarms have changed since 2005. Methods The Healthcare Technology Foundation's Clinical Alarms Committee developed an online survey for hospital personnel that addressed attitudes and practices related to clinical alarms. They administered it in 2005-2006 and in 2011 and compared the results. Results Respondents were asked about their level of agreement with 19 statements about alarms. Many of the statements revealed no significant differences between the 2 survey years, although some differences were apparent. Respondents to the 2011 survey were significantly more likely to agree with statements about alarm sounds differentiating the priority of alarm and the helpfulness of central alarm management. Respondents in 2011 were significantly less likely to feel that nuisance alarms occur frequently and disrupt patient care. Respondents also ranked the importance of 9 different alarm issues. In both years, they ranked frequent false alarms as the most important. In response to a new question in the 2011 survey, 18% of respondents reported patients' experiencing adverse events related to alarms at their institutions. Conclusions Since 2005-2006 when the first survey was conducted, not much has changed. False alarms continue to contribute to a noisy hospital environment, and sentinel events related to alarm fatigue persist. Alarm hazards are a significant patient safety issue. [ABSTRACT FROM AUTHOR]

Background: Intracranial pressure is a frequent target for goal- directed therapy to prevent secondary brain injury. In critical care settings, nurses deliver many interventions to patients having intracranial pressure monitored, yet few data documenting the immediate effect of these interventions on intracranial pressure are available. Objective: To examine the relationship between intracranial pressure and specific nursing interventions observed during routine care. Methods: Secondary analysis of prospectively collected observational data. Results: During 3118 minutes of observation, 11 specific nursing interventions were observed for 28 nurse-patient dyads from 16 hospitals. Family members talking in the room, administering sedatives, and repositioning the patient were associated with a significantly lower intracranial pressure. However, intracranial pressure was sometimes higher, lower, or unchanged after each intervention observed. Conclusion: Response of intracranial pressure to nursing interventions is inconsistent. Most interventions were associated with inconsistent changes in intracranial pressure at 1 or 5 minutes after the intervention. (American Journal of Critical Care. 2013;22:431-438) [ABSTRACT FROM AUTHOR]

The article features the evidence-based module TeamSTEPPS training tool released by the U.S. Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense for care delivery and patient safety improvement.

Background: The reported incidence of pressure ulcers in critically ill infants and children is 18% to 27%. Patients at risk for pressure ulcers and nursing interventions to prevent the development of the ulcers have not been established. Objectives: To determine the incidence of pressure ulcers in critically ill children, to compare the characteristics of patients in whom pressure ulcers do and do not develop, and to identify prevention strategies associated with less frequent development of pressure ulcers. Methods: Characteristics of 5346 patients in pediatric intensive care units in whom pressure ulcers did and did not develop were compared. Multiple logistic regression was used to determine which prevention strategies were associated with less frequent development of pressure ulcers. Results: The overall incidence of pressure ulcers was 10.2%. Patients at greatest risk were those who were more than 2 years old; who were in the intensive care unit 4 days or longer; or who required mechanical ventilation, noninvasive ventilation, or extracorporeal membrane oxygenation. Strategies associated with less frequent development of pressure ulcers included use of specialty beds, egg crates, foam overlays, gel pads, dry-weave diapers, urinary catheters, disposable underpads, body lotion, nutrition consultations, change in body position every 2 to 4 hours, blanket rolls, foam wedges, pillows, and draw sheets. Conclusions: The overall incidence of pressure ulcers among critically ill infants and children is greater than 10%. Nursing interventions play an important role in the prevention of pressure ulcers. [ABSTRACT FROM AUTHOR]

The article reports on the findings of a descriptive study conducted in a 12-bed surgical intensive care unit (SICU) of a regional medical center in Midwestern U.S., which examines the use of nighttime lighting in SICU. The study revealed the association between blood samples collection for laboratory test and the amount of nighttime exposure to light in ICU. Further, it showed the importance of using nighttime lighting for minimizing the use of other disruptive light sources.

Background The Therapeutic Intervention Scoring System is widely used in both Western Europe and the United States to assess the level of patients' need for nursing care. Poland currently has 3 types of intensive care according to a territorial division of the country and the scope of medical treatment offered: poviat, voivodeship, and clinical. Objective To determine the need for nursing care for patients in the 3 types of intensive care units in southeastern Poland. Methods The investigation was conducted at 6 intensive care units in southeastern Poland in 2005 and 2006. Two units were randomly selected from each type of intensive care unit. A total of 155 patients from the units were categorized according to scores on the Therapeutic Intervention Scoring System 28. Results Among the 3 types of units, patients varied significantly with respect to age, length of hospitalization, and scores on the Therapeutic Intervention Scoring System 28. Nevertheless, demand for nursing care during night and day shifts was similar in all 3 types. On the basis of the patients' scores, all 3 types of units provided appropriate staffing levels necessary to meet the demands for nursing care. Most patients required category III level of care. Conclusion Need or demand for nursing care in intensive care units in Poland varies according to the type of intensive care unit and can be determined on the basis of scores on the Therapeutic Intervention Scoring System 28. [ABSTRACT FROM AUTHOR]

The Centers for Disease Control and Prevention recently updated guidelines for isolation precautions and added specific recommendations for the management of multidrug-resistant organisms. However, the extent to which these recommendations are followed is unknown. Although the recommendations are based on studies with high internal validity, the effectiveness of these interventions in clinical practice also is unknown. Evidence of the effectiveness of isolation precautions for preventing transmission of infections caused by multidrug-resistant organisms in acute care settings, with methicillin-resistant Staphylococcus aureus as an example, was reviewed. Despite a lack of experimental data, numerous descriptive and correlational studies and a sound theoretical rationale strongly suggest that barrier precautions play an important role in the prevention of transmission of infections due to multidrug-resistant organisms. Two major problems, however, still exist. First, staff members' adherence to national recommendations on isolation precautions, although insufficiently described, appears to be inadequate. Second, efficient, reproducible methods for ongoing surveillance of practices such as isolation precautions are not readily available. Automated surveillance systems that provide support for making decisions are promising for this purpose, are likely to result in cost savings, and therefore warrant more widespread development, testing, and implementation. [ABSTRACT FROM AUTHOR]

The article focuses on the Work Environment Standards and the Empowering Nurse Advancement System of the American Association of Critical-Care Nurses (AACCN) in the U.S. It notes that both play an important role in the delivery of utmost patient care by nurses and provide opportunities for them. It adds that nurse advancement systems generate positive outcomes that are important to the people in the health care profession.

The article reports on a malpractice lawsuit simulation that was used to teach members of a critical care health team bout the complexities of health care law and to help make them aware of the possibilities of litigation that critical care professionals face. An overview of financial costs that U.S. hospitals face annually as a result of medical lawsuits is presented.

The article presents information on a follow-up report about the work environments of critical care nurses in the U.S. in 2008. A brief overview is given on American Association of Critical-Care Nurses (AACN) healthy work environment standards. It explores the assessments by nurses of the status of their work environments. It explains the leadership competencies of nurse managers and chief nurse executives.

Nurses are needed more than ever to support the healthcare needs of every American. Nurses make up the greatest single component of hospital staff. In 2004, of the almost 3 million nurses in the United States, 83% were employed in nursing, and 58% of those were employed full-time. However, a severe shortage of nurses exists nationwide, putting the safe, effective healthcare of Americans in jeopardy. The concurrent shortage of nursing faculty has significant impact on the potential for admitting and graduating sufficient numbers of nursing students to address the shortage of prepared nurses. A close examination of the demographics of the 3 million nurses provides a context for an in-depth discussion of strategies that critical care nurses can employ to help alleviate the nursing and nurse faculty shortages. [ABSTRACT FROM AUTHOR]

The article discusses the diagnosis, prevention, treatment for Clostridium difficile-associated disease (CDAD) and the nursing care required for patients with CDAD. CDAD is diagnosed based on signs and symptoms. Three elements are required for the prevention of CDAD and the U.S. Centers for Disease Control and Prevention has issued guidelines for preventing CDAD. Various drug treatments are suggested for CDAD and their efficacy. There are several goals of nursing care for CDAD patients.

The article discusses the current controversies in organ donation in the U.S. The dead donor rule was established in the context of organ donation to provide a societal assurance that organ recovery would not cause the death of a potential donor. The author has reacted the risks of premortem use of heparin in donation after cardiac death patients.

The article presents a study on the importance of specialty certification in nurses and other health professionals in the U.S. Certifications are provided by the National Commission for Certifying Agencies for individuals to serve the public with their knowledge on specific area of practice. Specialty nursing certification is the basis of the public for quality nursing care. Results of surveys conducted by several nursing associations regarding certification of nurses are discussed.

Cardiovascular disease is the No. 1 killer of women in the United States, and marked disparities in cardiovascular health exist between women and men and among groups of women. Coronary heart disease is underdiagnosed, undertreated, and underresearched in women. Women with suspected heart disease are less likely than men to receive indicated diagnostic tests and procedures; sex-based biases in treatment of myocardial infarction persist; and women continue to be underrepresented in cardiovascular research. An accumulating body of literature points to 3 major explanations: sex-based physiology, provider bias, and psychosocial influences. Women's acute and prodromal signs and symptoms of myocardial infarction have been described, yet women have difficulty recognizing and acting on these indications. Primary and secondary prevention of heart disease in women is imperative; although the science is lacking in several areas, existing evidence on diet, hormone therapy, aspirin, physical activity and obesity, and diabetes can serve as the basis for interventions. Potentially, large impacts could be made on women's morbidity and mortality if current scientific knowledge were implemented. The state of the science of women and heart disease is reviewed, with a focus on those areas with the greatest potential to address the needs of women's cardiovascular status. Key gaps in the science and remaining questions are presented as a research agenda for the coming decade. [ABSTRACT FROM AUTHOR]

The article discusses the results of a survey of critical care nurses' work environments in the U.S., which was conducted by the American Association of Critical-Care Nurses, Nursing Spectrum and Bernard Hodes Group in 2006. Physical and mental safety in terms of discrimination, sexual harassment, discrimination, physical abuse and verbal abuse were assessed.

Presents information on the Organ Transplantation Breakthrough Collaborative initiated by the U.S. Department of Health and Human Services to make improvements in every aspect of the organ donation and transplanting system in the country. Goal of the collaborative; Factors being considered by the collaborative in identifying potential organ donors; Benefits of increasing number of transplantation.

Discusses the philosophical perspective behind the shift from the standard approach to presumptive approach to consent in organ donation. History of organ donation and the standard approach; Elements of the presumptive approach that provide donation requestors a framework in which to understand presumptivity; Impact of presumptive approach on organ donation rates.

This article focuses on academic degrees related to nursing in the U.S. Nursing as a profession appears destined to argue about educational preparation. This year one celebrates the 40th anniversary of the American Nurses Association's resolution that entry into practice will be at the bachelor's degree level. In October 2004, the American Association of Colleges of Nursing passed a resolution to support the doctor of nursing practice as a terminal practice degree. The degree is to be distinguished from the PhD, which has wide acceptance as a research-focused degree, and is to supplant the master's degree.

The article provides information about American Association of Critical-Care Nurses (AACN). Acute and critical care nurses repeatedly voice grave concern and moral distress about the deterioration of healthcare work environments in the United States. The article also reflects on some of the cases that represent countless incidents occurring in American hospitals each day, showing the devastating impact of unhealthy work environments on the effectiveness of the American healthcare system. AACN recognizes the inextricable links among quality of the work environment, excellent nursing practice, and patient care outcomes.

Describes the elements of the successful approach of critical care registered nurses (CCRN) certification drive implemented at Deaconess Hospital in Evansville, Indiana. Theoretical framework of the levels of proficiency applicable to the nursing profession; Execution of the plan for the CCRN drive; Discussion on the results of the drive.

Part I. Deals with nursing techniques in the management of traumatic brain injury in critical care settings in the U.S. Dynamics of brain injury related to oxygen; Historical perspectives on brain tissue oxygen monitoring; Measurement and safety of brain tissue oxygen monitoring.

Discusses the contribution of certified nurses to patient care in the U.S. Healthcare needs of U.S. aging population; Definition of critical care nursing; Impact of family needs on critical care nurses' ability to deliver the right care at the right time.

The author discusses vaccine hesitancy as a reason for low vaccination rates. Topics mentioned include components that contribute to vaccine hesitancy such as issues of confidence, complacency and convenience, reasons measles outbreaks should matter to critical care providers such as how measles outbreak result in critical care admissions that could be prevented and the need for a provider to encourage patient to trust him as a knowledgeable expert who provides accurate information.

The author reflects on the growth and development of critical care nursing and of the publication "American Journal of Critical Care." She observes that critical care nursing and the profession of nursing have developed remarkably. The number of nurses in the U.S. has increased dramatically in the past 3 decades from 1 million in 1980 to 3 million. Relatively, the journal has also evolved by embracing and promoting multidisciplinary collaboration.

The authors offer their insights regarding the challenge of patient transfer, also knows as handoff, in the U.S. According to a medical survey, most medical schools pay little or no attention to safe handoffs. The authors suggest that the elements of safe handoffs should be taught to students to maximize patient safety.

The article focuses on the impact of poverty on the healthcare system in the U.S. It discusses several issues that affect critical care clinicians everyday. These include the impact of poverty on health outcomes in developed countries such as the U.S., the quality of healthcare that the U.S. provides its citizens, and the issue of recruiting healthcare personnel from developing countries who seek to better their lives by immigrating to the U.S.

Comments on the role of critical care nurses in the improvement of organ donation in the U.S. Estimated number of actual organ donors in 2002, according to the Department of Health and Human Services (DHHS); Goal of the Organ Donation Breakthrough Collaborative initiated by DHHS in 2003; Topics discussed at the National Learning Congress on Organ Donation held in May 2005.

Deals with the implications of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for clinicians in the U.S. Provisions of the HIPAA; Impact of HIPAA regulations on clinicians-patient communication; Probable cost of implementing the HIPAA.

An abstract of the article "Caring for a Family Member with a Left Ventricular Assist Device as Destination Therapy: Changes in the Tasks of Caregiving After Implantation," by Judith Hupcey and Lisa Kitko is presented.

An abstract of the article "Barriers and Facilitators to Quality End-of-Life Care for Children," by Renea Beckstrand is presented.

An abstract of the article "Barriers to Compliance with Ventilator Bundles in the Intensive Care Unit," by Timothy Madeira and Andrea Jones is presented.