Search

Background: Pandemics and the large-scale outbreak of infectious disease can significantly impact morbidity and mortality worldwide. The impact on intensive care resources can be significant and often require modification of service delivery, a key element which includes rapid expansion of the critical care workforce. Pandemics are also unpredictable, which necessitates rapid decision-making and action which, in the lack of experience and guidance, may be extremely challenging. Recognising the potential strain on intensive care units (ICUs), particularly on staffing, a working group was formed for the purpose of developing recommendations to support decision-making during rapid service expansion., Methods: The Critical Care Pandemic Staffing Working Party (n = 21), representing nursing, allied health, and medical disciplines, has used a modified consensus approach to provide recommendations to inform multidisciplinary workforce capacity expansion planning in critical care., Results: A total of 60 recommendations have been proposed which reflect general recommendations as well as those specific to maintaining the critical care workforce, expanding the critical care workforce, rostering and allocation of the critical care workforce, nurse-specific recommendations for staffing the ICU, education support and training during ICU surge situations, workforce support, models of care, and de-escalation., Conclusion: These recommendations are provided with the intent that they be used to guide interdisciplinary decision-making, and we suggest that careful consideration is given to the local context to determine which recommendations are most appropriate to implement and how they are prioritised. Ongoing evaluation of recommendation implementation and impact will be necessary, particularly in rapidly changing clinical contexts., (Copyright © 2020 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Hospital leaders, policymakers and healthcare professionals are realising the benefits of delivering care that promotes family participation because it is known to enhance the quality of care, and improve patient satisfaction., Aim: The aim of this study was to explore, from the perspective of patients and family members within an adult acute care ward: (a) their beliefs and attitudes towards family participation in patient care and (b) staff behaviours that support or hinder family participation in patient care., Design and Methods: A naturalistic approach with an exploratory sequential design was used in a medical assessment and planning unit of a regional referral hospital in Australia. Purposeful maximum variation sampling was used to recruit patients and family members who differed in age, ethnicity, relationship to patient and gender. Observer-as-participant observation data and semi-structured interviews were undertaken. Following separate inductive content analysis, data were triangulated., Results: Thirty-two patients and 26 family members were recruited. Thirty hours of observational data were gathered. Eighteen patients and 15 family members were interviewed. Analysis uncovered two contrasting categories: (a) disconnected communication and (b) family influence quality., Conclusion: The findings of our study demonstrated that most patients and families perceived staff communication as disconnected and inadequate, which constrained them from engaging in care processes or decision-making. However, when family felt empowered and participated in patient care, the quality of health care was enhanced. Healthcare professionals can use these findings to make informed evidence-based changes to the way they practice and communicate to ensure family participation in patient care is optimised in the acute care setting., (© 2018 Nordic College of Caring Science.)

Recovery after critical illness can be protracted and challenging. Compromise of physical, psychological, cognitive and social function is experienced by some patients and may persist for a number of years. Measurement of recovery outcomes at regular time points throughout the critical illness and recovery pathway is necessary to identify problems and guide selection of interventions to prevent, minimise or overcome that compromise. Optimisation of factors that enhance recovery, such as sleep, nutrition and memories of intensive care, will also assist with promotion of recovery. Effective assessment of recovery requires integration of assessment of outcomes into routine clinical practice by all members of the interdisciplinary team. There must be agreement of appropriate measures and measurement timeframes alongside relevant education and training to ensure optimal assessment and use of the information gained. Assessment outcomes need to be communicated to interdisciplinary team members across the critical illness and recovery trajectory. Adequate resourcing for both the assessment activities and subsequent care is essential to improve patient outcomes after critical illness., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Introduction: Selective decontamination of the digestive tract (SDD) is a prophylactic antibiotic regimen that is not widely used in practice. We aimed to describe the opinions of key 'stakeholders' about the validity of the existing evidence base, likely consequences of implementation, relative importance of their opinions in influencing overall practice, likely barriers to implementation and perceptions of the requirement for further research to inform the decision about whether to embark on a further large randomised controlled trial., Methods: This was a Delphi study informed by comprehensive framework of possible determinants of health professionals' behaviour to study Critical Care practice in four countries. There were four key stakeholder participant groups including ICU physicians, pharmacists, clinical leads, and clinical microbiologists/ infectious disease physicians. Round one comprised participant interviews and Rounds two and three were online questionnaires using Delphi method., Results: In this study, 141 participants were recruited of whom 82% were retained. Participants rated themselves as knowledgeable about SDD. Antibiotic resistance was identified as the most important issue. SDD was seen as a low clinical priority but few participants reported strong opposition. There was moderate agreement that research to date has not adequately addressed concerns about antibiotic resistance and lacks generalizability. Participants indicated equipoise with regard to benefits and harms of SDD, and indicated strong support for a further randomised trial., Conclusions: Clinicians have clinical equipoise about the effectiveness of SDD. Future research requires longer follow up to assess antibiotic resistance as well as greater validity/generalizability to provide definitive answers on the effectiveness of decontamination and effects on antibiotic resistance. SDD was regarded as not being a high clinical priority, which may limit future trial participation. These results have identified that further large randomised controlled trial of SDD in critical care is both warranted and appropriate.

Observational studies have consistently revealed wide variation in nutritional practices across intensive care units and indicated that the provision of adequate nutrition to critically ill patients is suboptimal. To date, the potential role of critical care nurses in implementing nutritional guideline recommendations and improving nutritional therapy has received little consideration. Factors that influence nurses' nutritional practices include the lack of guidelines or conflicting evidence-based recommendations pertaining to nurses' practice, strategies for implementing guidelines that are not tailored to barriers nurses face when feeding patients, strategies to communicate best evidence that do not capitalize on nurses' preference for seeking information through social interaction, prioritization of nutrition in initial and continuing nursing education, and a lack of interdisciplinary team collaboration in the intensive care unit when decisions on how to feed patients are made. Future research and quality improvement strategies are required to correct these deficits and successfully empower nurses to become nutritional champions at the bedside. Using nurses as agents of change will help standardize nutritional practices and ensure that critically ill patients are optimally fed.

Background: Variability in clinical practice may result from the use of diverse information sources to guide clinical decisions. In routine clinical practice, nurses privilege information from colleagues over more formal information sources. It is not clear whether similar information-seeking behaviour is exhibited when critical care nurses make decisions about a specific clinical practice, where extensive practice variability exists alongside a developing research base., Purpose: This study explored the preferred sources of information intensive care nurses used and their perceptions of the accessibility and usefulness of this information for making decisions in clinically uncertain situations specific to enteral feeding practice., Methods: An instrumental case study design, incorporating concurrent verbal protocols, Q methodology and focus groups, was used to determine intensive care nurses' perspectives of information use in the resolution of clinical uncertainty., Findings: A preference for information from colleagues to support clinical decisions was observed. People as information sources were considered most useful and most accessible in the clinical setting. Text and electronic information sources were seen as less accessible, mainly because of the time required to access the information within the documents., Discussion: When faced with clinical uncertainty, obtaining information from colleagues allows information to be quickly accessed and applied within the context of a specific clinical presentation. Seeking information from others also provides opportunities for shared decision-making and potential validation of clinical judgment, although differing views may exacerbate clinical uncertainty., Conclusions and Implications for Practice: The social exchange of clinical information may meet the needs of nurses working in a complex, time-pressured environment but the extent of the evidence base for information passed through verbal communication is unclear. The perceived usefulness and accessibility of information is premised on the ease of use and access and thus the variability in information may be contributing to clinical uncertainty., (Copyright ©2011 Sigma Theta Tau International.)

Aims: This study was designed to examine the decision making processes that nurses use when assessing and managing sedation for a critically ill patient, specifically the attributes and concepts used to determine sedation needs and the influence of a sedation guideline on the decision making processes., Background: Sedation management forms an integral component of the care of critical care patients. Despite this, there is little understanding of how nurses make decisions regarding assessment and management of intensive care patients' sedation requirements. Appropriate nursing assessment and management of sedation therapy is essential to quality patient care., Design: Observational study., Methods: Nurses providing sedation management for a critically ill patient were observed and asked to think aloud during two separate occasions for two hours of care. Follow-up interviews were conducted to collect data from five expert critical care nurses pre- and postimplementation of a sedation guideline. Data from all sources were integrated, with data analysis identifying the type and number of attributes and concepts used to form decisions., Results: Attributes and concepts most frequently used related to sedation and sedatives, anxiety and agitation, pain and comfort and neurological status. On average each participant raised 48 attributes related to sedation assessment and management in the preintervention phase and 57 attributes postintervention. These attributes related to assessment (pre, 58%; post, 65%), physiology (pre, 10%; post, 9%) and treatment (pre, 31%; post, 26%) aspects of care., Conclusions: Decision making in this setting is highly complex, incorporating a wide range of attributes that concentrate primarily on assessment aspects of care., Relevance to Clinical Practice: Clinical guidelines should provide support for strategies known to positively influence practice. Further, the education of nurses to use such guidelines optimally must take into account the highly complex iterative process and wide range of data sources used to make decisions.

Objective: The Intensive Care Collaborative project was established with the specific aim of developing recommendations for clinical practice that are underpinned by the best available evidence to support the objective of improving the standard of care delivered in NSW Intensive Care Units. The eyecare clinical practice guideline for intensive care patients were developed as a result of this initiative., Methods: Search: The bibliographic databases (PubMed; The Cummulative Index of Nursing and Allied Health Literature (CINAHL); Medline and The Cochrane Library) were searched. The search terms used alone and in combination were: intensive care; prevention; eye; eyecare; and guidelines. In addition, reference lists of relevant papers were assessed to identify additional studies and Google Scholar was searched using the keywords eyecare and intensive care. The search strategy was limited to the English language but was not limited by year of publication. Study selection criteria: All relevant observational and interventional studies were included, regardless of study design. Review process: Each paper was reviewed by at least two Guideline Development Network (GDN) members independently using a data extraction tool. Papers were assessed against the National Health and Medical Research Council (NHMRC) levels of evidence. Recommendations were assigned using a modified Delphi process to ensure consensus., Summary of Recommendations: We recommend that each patient is assessed for the risk factors of iatrogenic ophthalmologic complications; the ability to maintain eyelid closure; for iatrogenic ophthalmologic complications. It is also recommended that; the rates of iatrogenic ophthalmologic complications are monitored; referral is made in a timely manner for any suspected iatrogenic ophthalmologic complications; eyelid closure is maintained if eyelid closure cannot be maintained passively; all patients who cannot achieve eyelid closure independently should receive eye care every 2h., Conclusions: The recommendations from this clinical practice guideline were peer-reviewed and examined by ophthalmology experts. Despite the heavy reliance on only a small number of studies and low level of evidence, the recommendations have the potential to positively affect patient outcomes by encouraging clinicians to assess and monitor for ophthalmological complications and to provide appropriate preventative interventions if implemented extensively.

Objective: This study was designed to prioritise educational outcomes for three levels of postgraduate speciality critical care nursing programmes., Background: Postgraduate speciality education has proliferated within Australia over the past 20 years. However, there is little agreement regarding the expected characteristics, or relevant priorities, of these characteristics of graduates successfully completing these programmes of study., Method: This study used a mixed-method approach comprising two phases. Initially a survey was mailed to volunteers between March and June 2005 to obtain priorities in educational outcomes for graduates of critical care programmes. This was followed by a stakeholder focus group in May 2006 to refine expected outcomes., Results: Survey respondents rated educational outcomes that described professional and legal aspects of practice to ensure safe patient care as highest priority for programme graduates. Although most educational outcome statements were considered important for graduates from all levels of courses, increasing levels of practice was described for increasingly higher levels of programmes from Graduate Certificate to Masters Degree., Conclusion: This study provides an emerging description of the priorities of critical care nursing programmes, with priority given to professional and legal aspects of practice. Further delineation of priorities is necessary to inform ongoing educational development.

Background: Educational preparation for critical care nursing in Australia varies considerably in terms of the level of qualification resulting in a lack of clarity for key stakeholders about student outcomes., Objectives: The study aim was to identify and reach consensus regarding the desired learning outcomes from Australian post-registration critical care education programs as demonstrated through the graduate's knowledge, skills and attitudes., Design: A Delphi technique was used to establish consensus between educators, managers, clinicians and students regarding learning outcomes expected of graduates with a Graduate Certificate, Graduate Diploma and Master level qualification in critical care nursing., Participants: A total of 164 critical care nurses (66 clinicians, 48 educators, 32 managers and 18 students) participated and 99 questionnaires were returned in the first round (response rate 60%). Fifty-seven questionnaires were returned for Round 2 (response rate 58%)., Methods: Learning outcomes were obtained from the Australian College of Critical Care Nurses Competency Standards for Specialist Critical Care Nurses. Some statements included more than one characteristic, and these were split to create learning outcomes with one characteristic per item. A survey of Australian higher education providers of critical care education provided additional learning outcomes, for a total of 73 learning outcomes for the first Delphi round., Results: Findings suggest that patient comfort, safety, professional responsibility and ethical conduct are deemed most important for all three levels of educational preparation. There was a lack of emphasis on clinical practice issues for all levels. Participants placed higher emphasis on learning outcomes related to complex decision-making, leadership, supervision, policy development and research for Graduate Diploma and Master level programs., Conclusion: The findings have implications for curriculum development and the profession with regards to the level of educational preparation required of critical care nurses and suggest that further work is required before clear recommendations can be made for desired educational outcomes from critical care nursing programs in Australia.

Introduction: Enteral feeding is the preferred method of nutritional support for the critically ill; however, a significant number of these patients are under-fed. It is possible that common nursing practices associated with the delivery of enteral feeding may contribute to under-feeding although there is little data available describing nursing practice in this area., Method: A descriptive survey-based design was used to explore the enteral feeding practices of 376 critical care nurses (response rate 50.5%). Participants completed a 57-item survey that focused on general enteral feeding practice and the management of feeding intolerance and complications., Results: The enteral feeding practice of critical care nurses varied widely and included some practices that could contribute to under-feeding in the critically ill. Practices associated with the measurement of gastric residual volumes (GRV) were identified as the most significant potential contributor to under-feeding. GRV measurements were commonly used to assess feeding tolerance (n = 338; 89.9%) and identified as a reason to delay feeding (n = 246; 65.4%). Delayed gastric emptying was frequently managed by prokinetic agents (n = 237; 63%) and decreasing the rate of feeding (n = 247; 65.7%) while nursing measures, such as changing patient position (n = 81; 21.5%) or checking tube placement (n = 94; 25%) were less frequently reported., Conclusion: The findings of this survey support the contention that nursing practices associated with the delivery of enteral feeds may contribute to under-feeding in the critically ill patient population.

Objective: To determine the construct validity of the Australian College of Critical Care Nurses (ACCCN) competency standards as a tool for assessing the clinical practice of specialist level critical care nurses in Australia., Design: A comparative descriptive design was used to examine the relationship between the domains, competencies and elements of the ACCCN competency standards. Participants were sent a questionnaire and asked to describe on a 7-point Likert scale how closely each competency statement and related elements reflected their level of critical care nursing practice., Subjects: A systematic sampling method was used to randomly select 1000 critical care nurses from a prelisting of members of ACCCN. A total of 532 completed questionnaires were returned., Main Outcome Measure: The purpose of this study was to determine the construct validity of the ACCCN competency standards by examining two structural models. The first examined how well the descriptive elements fit with their respective competency standard. The second model examined how well the competency standards group together under specific domains., Results: Statistically there was no support for the current structure for the ACCCN competencies because the elements did not fit uniquely to a single competency, but were multidimensional and loaded across several competencies. Competency statements also loaded across several domains. Modification of the current model resulted in the identification of a four-factor competency model, which demonstrated reasonable model fit., Conclusion: Several issues are highlighted, resulting in concerns regarding the validity of the ACCCN Competency Elements and Standards as a tool with which to assess the practice of critical care nurses.

Background: Gastric tonometry is used to assess gastrointestinal mucosal perfusion in critically ill patients. However, enteral feeding is withheld during monitoring with gastric tonometry because enteral feeding is thought to influence tonometric measurements., Objectives: To examine the effect of enteral feeding on the tonometric measurement of gastric mucosal carbon dioxide., Methods: Gastric tonometers were placed in 20 critically ill patients, and the PCO2 of the gastric mucosa was measured in both the full and the empty stomach during a 48-hour period., Results: The PCO2 measured by the tonometer increased after enteral feeding, and a significant difference in the PCO2 of the full versus the empty stomach was evident at 24 and 48 hours. PCO2 at 4, 24, and 48 hours differed significantly in the full stomach and in the empty stomach. However, the data did not reveal a significant difference in either the full stomach or the empty stomach between PCO2 at 24 hours and PCO2 at 48 hours., Conclusion: After 24 hours of feeding, the initial increase in PCO2 observed at 4 hours was not evident, suggesting stabilization of the intragastric environment. However, a higher PCO2 was evident in the empty stomach, indicating that the presence of the feeding solution may reduce the diffusion of carbon dioxide into the tonometer balloon. Consequently, measurements of intragastric PCO2 obtained after 24 hours of feeding may be reliable if the stomach is emptied by aspiration via the tonometer immediately before measurement.

BackgroundOver the last decade, health care delivery has shifted to partnering with patients and their families to improve health and quality of care, and to lower costs. Partnering with family members (FMs) of critically ill patients who lack capacity is particularly important for improving experiences and outcomes for both patients and FMs. How best to apply such partnering strategies, however, is yet unknown. The IMPACT trial will evaluate two interventions that enable partnerships with families of critically ill patients, each in a distinct content area, but similar in that they empower and support FMs.MethodsThis multi-center, open-label, randomized, phase II clinical trial aims to randomize 150 older, long-stay ICU patients and their families into one of three groups (50 in each group): (1) The OPTimal nutrition by Informing and Capacitating FMs of best practices (OPTICs) group, a multi-faceted intervention to engage and empower FMs to advocate for, and audit, best nutritional practices for their critically ill FMs, (2) A web-based decision-support intervention called the ICU Workbook (The Canadian Researchers at the End of Life Network (CARENET) ICU Workbook; https://www.myicuguide.ca/. Accessed 3 Feb 2017.) to support families in shared decision-making process regarding goals of medical treatments, and (3) Usual care. The main outcomes for this trial include nutritional adequacy in hospital and hand-grip strength prior to hospital discharge; satisfaction with decision-making; decision conflict; and degree of shared decision-making.DiscussionWith the goal of improving the functional recovery of nutritionally high-risk older patients and the quality of care at the end of life for these patients and their FMs in the ICU, we have proposed two novel family capacitation strategies. We hope that the nutrition and decision-support interventions implemented and evaluated in our study will contribute to the evidentiary basis for best family partnered care pathways focused on optimizing the quality of ICU care for patients with life-threatening illness and their families.Trial registrationClinical trials.gov, ID: NCT02920086. Registered on 30 September 2016. Protocol version dated 11 October 2016.

Background: Critical illness significantly impacts the well‐being of patients and families. Previous studies show that family members are willing to participate in patient care. Involving families in early mobility interventions may contribute to improved recovery and positive outcomes for patients and families. Aim: In this scoping review, we investigated early mobility interventions for critically ill patients evaluated in randomized controlled trials and the extent to which family engagement in those interventions are reported in the literature. Study Design: In this scoping review of reviews, EMBASE, CINAHL, PubMed and Cochrane Central databases were searched in October 2019 and updated in February 2022. Systematic reviews were included and assessed using A MeaSurement Tool to Assess Systematic Reviews (AMSTAR) 2. Data were synthesized using a narrative approach. PRISMA‐ScR guidelines were adhered to for reporting. Results: Thirty‐three reviews were included which described a range of early mobility interventions for critically ill patients; none explicitly mentioned family engagement. Almost half of the reviews were of low or critically low quality. Insufficient detail of early mobility interventions prompted information to be extracted from the primary studies. Conclusions: There are a range of early mobility interventions for critically ill patients but few involve families. Given the positive outcomes of family participation, and family willingness to participate in care, there is a need to explore the feasibility and acceptability of family participation in early mobility interventions. Relevance to Clinical Practice: Family engagement in early mobility interventions for critically ill patients should be encouraged and supported. How to best support family members and clinicians in enacting family involvement in early mobility requires further investigation. [ABSTRACT FROM AUTHOR]

Background: The decision to conduct a randomized controlled trial (RCT) in a field raises ethical as well as scientific issues. From the clinical equipoise literature, future trials are justifiable if there is "honest, professional disagreement in the community of expert practitioners as to the preferred treatment". Empirical data are sparse about how clinicians apply the principles of equipoise to the justification of future RCTs. For example, selective decontamination of the digestive tract (SDD) is not widely used in critical care practice despite the strength of the evidence base and therefore provides a unique opportunity to learn how clinicians think about the ethics of further RCTs in critical care.Methods: In an international interview study of views of healthcare professionals about SDD, we undertook a secondary analysis of qualitative data collected using a Theoretical Domains Framework of clinical behaviour. We adopted a general descriptive approach to explore how physicians determined whether another RCT of SDD is ethical. Following a constant comparison approach, three investigators reviewed 54 purposively chosen transcripts from three international regions. We interpreted the data using thematic analysis.Results: We grouped participants' responses into four inter-related themes: 1) cultural norms about evidence and practice within healthcare; 2) personal views about what evidence is current or applicable; 3) the interpersonal and relational nature of professional decision making locally; and 4) an a priori commitment to future trials. The analysis also identified several unresolved tensions regarding when a future RCT should be pursued. These tensions focused on a clash between potential benefits to current individual patients and potential future harms to patients more broadly.Conclusions: Our study suggests that ethical decision making about future RCTs in the field of SDD does not rely strongly on appeals to evidence, even when the quality of the evidence is reasonably high. Rather, "extra-evidential" reasons, including social, professional, and relational factors, seem to influence opinions regarding the ethics of future trials. Further work is required to see if these conclusions are applicable to other clinical topics and settings. [ABSTRACT FROM AUTHOR]

Early mobilisation is beneficial to minimise complications and promote the recovery and physical function of critically ill adult patients. An interprofessional team approach may assist in early mobilisation of these patients; however, adopting this approach may be challenging and optimal strategies to support early mobilisation are unknown. Understanding specific implementation strategies is required to effectively support its implementation in the critically ill adult patient population. To synthesise and critically analyse the literature on interprofessional team approaches to early mobilisation in critically ill adult patients. An integrative review The methodology of this integrative review was guided by Whittemore and Knafl's approach. A literature search of online databases including Cumulative Index to Nursing and Allied Health Literature, Excerpta Medica database, Medical Literature Analysis and Retrieval System Online, Physiotherapy Evidence Database, and PubMed was conducted on 13 April 2020 and updated on 2 August 2021. No date limits were applied. Backward citation searching of included articles was used to identify additional articles. Articles were screened by title and abstract following pre-specified inclusion and exclusion criteria, and then by full text using the same criteria. Data describing an interprofessional team approach to early mobilisation were extracted into a specifically designed form. Quality appraisal was undertaken using the Quality Improvement Minimum Quality Criteria Set for quality improvement studies and the Joanna Briggs Institute's critical appraisal tools was used for cohort studies, retrospective studies, and randomised controlled trials. A narrative synthesis was conducted to integrate and summarise the findings. Thirty-seven studies were included. All studies described team compositions, roles, and responsibilities. Multiple strategies were used to support the implementation of a team approach to early mobilisation, most of which included the use of instruction tools, team meetings/team rounds, staff education, and knowledge sharing, and safety criteria. Improving patient's readiness to perform early mobilisation using clinical interventions was also described in 17 studies. Crucial factors that can help or hinder the implementation of an interprofessional team approach to early mobilisation were identified including organisational structure, staff attitudes and staff abilities. An interprofessional team approach to early mobilisation may be a useful strategy to improve early mobilisation practice; however, team compositions, roles, and responsibilities to support its implementation in individual setting is recommended. Multiple strategies and clinical interventions should be used to overcome barriers for implementing an interprofessional team approach to early mobilisation in critically ill adult patients. Registration number: This review was registered into PROSPERO International prospective register of systematic review (CRD42020179943). Use of an interprofessional team approach to improve early mobilisation practice in adult critically ill patients. [ABSTRACT FROM AUTHOR]