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Background: Delirium is prevalent in hospitalized older adults. Little is known about delirium among older adults admitted to the surgical intensive care unit (SICU)., Objectives: The purpose of this study was to describe the incidence of delirium, length of stay, 30-day readmission and mortality rates experienced by older adults in the SICU before and after a nurse-driven protocol for delirium-informed care., Methods: This study employed a retrospective observational cohort design. Consecutive patients 65 years or older admitted to the SICU over six-month periods were compared before (n = 101) and following (n = 172) a nurse-driven protocol for delirium-informed care. Patient-level outcomes included incidence delirium, SICU and hospital length of stay, 30-day readmission and mortality rates. All measures were collected using medical record review., Results: In the pre- and post-intervention cohorts, 37% (37/101) and 33% (56/172) of patients screened positive for delirium, respectively. Following implementation of the delirium-informed care intervention, the number of days where no CAM-ICU assessment was performed significantly decreased (Pre 1.1 ± 1.4; Post 0.45 ± 0.65; p <0.001) and the number of negative assessments significantly increased (Pre 2.45 ± 1.66; Post 2.94 ± 1.69; p < 0.0178), indicating that nurses post-intervention were more consistently assessing for delirium., Conclusions: This study failed to show improvements in patient outcomes (SICU and hospital length of stay, 30-day readmission and mortality rates), before and following a delirium-informed care intervention. However, positive trends in the data suggest that delirium-informed care has the potential to increase rates of assessment and delirium identification, thereby providing the foundation for reducing the consequences of delirium and improve patient-level outcomes. Further better controlled prospective work is needed to validate this intervention., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: This report presents up-to-date evidence and expert consensus-based revisions to the ASPMN 2011 guidelines that inform interprofessional clinical decision-making for hospitalized adults receiving opioid analgesics., Design: Systematic review of the literature., Methods: A 14-member expert panel was charged with reviewing and grading the strength of scientific evidence published in peer reviewed journals and revising the ASPMN 2011 existing guidelines. Panel members formulated recommendations based on the strength of evidence and reached consensus through discussion, reappraisal of evidence, and voting by majority when necessary. The American Society of Anesthesiologists evidence categories for grading and classifying the strength of the evidence were used. Recommendations were subjected to a critical review by ASPMN members as well as external reviews., Results: The 2011 guidelines were found to still be relevant to clinical practice, but new evidence substantiated refinement and more specific recommendations for electronic monitoring. The revised guidelines present risk factors divided into three categories: patient-specific, treatment-related, and environment of care. Specific recommendations for the use of electronic monitoring are delineated., Conclusions: All hospitalized patients that are administered opioids for acute pain are at risk of opioid induced advancing sedation and respiratory depression, but some patients are at high risk and require extra vigilance to prevent adverse events. All patients must be assessed for level of risk. Adaptations to the plan of care and monitoring strategies should be driven by iterative re-assessments according to level of risk., Nursing Practice Implications: Opioid medications continue to be a major component in the management of acute pain. Clinicians have the primary responsibility for safe and effective pain management. Evidence based monitoring strategies can improve patient safety with opioids., (Copyright © 2020 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the feasibility and impact of implementing the "study of patient-nurse effectiveness with assisted communication strategies-2" (SPEACS-2); a program to facilitate communication with nonvocal patients., Study Design: The plan-do-study-act quality improvement methodology guided the implementation of a modified SPEACS-2 program within a pre and posttest design. The Ease of Communication Scale (ECS) measured patients' communication difficulty, and care processes measured the program's success., Study Population: Nurses (N = 385) across 5 intensive care units were trained in SPEACS-2. We assessed 354 nonvocal patients (aged 18-95 years) requiring continued mechanical ventilation after withdrawal of heavy sedation. Patients were evaluated over one 2-week preintervention (n = 163) and two 3-week postintervention periods (n = 128; n = 63). A subsample of intervention patients (n = 204) completed the ECS., Results: Ease of Communication Scale scores improved significantly (p = .027) from baseline (mean 25.86 ± 12.2, n = 71) to postintervention period 2 (21.22 ± 12.2, n = 63). Nurses' use of communication techniques and compliance with communication plans of care incrementally increased after training., Conclusions: Implementing SPEACS-2 demonstrated positive changes in patients' ease of communication and feasibility of incorporating evidence-based communication strategies into practice.

The National Academy of Medicine recognizes medical errors as a leading cause of death in the United States. Hospitals nationwide have acted to improve patient safety, quality of care, and system processes; however, no standards mandate assessment of the emotional impact of perioperative catastrophes on healthcare professionals. A cross-sectional descriptive study using a sample of 196 Certified Registered Nurse Anesthetists (CRNAs) tested the psychometric properties of an adapted version of the Perioperative Catastrophes Survey and administered this survey along with the Ways of Coping Questionnaire to measure CRNAs' perceptions, experiences, and responses associated with perioperative catastrophes. The adapted survey demonstrated acceptable internal consistency reliability (α = .893) and construct validity (factor analysis), with 4 subscales explaining 68.1% of the variance in the measure. The CRNAs scored similarly to anesthesiologists in a prior study conducted by Gazoni and colleagues, showing that memorable perioperative catastrophes have a negative emotional, cognitive, and functional impact. On the 8 Ways of Coping Questionnaire subscales, CRNAs with less than 10 years of experience reported significantly higher Escape-Avoidance behaviors compared with more experienced CRNAs (P = .016). Future research must examine perceptions of perioperative catastrophic events and coping mechanisms to identify providers at risk of negative consequences., Competing Interests: The authors have declared no financial relationships with any commercial entity related to the content of this article. The authors did not discuss off-label use within the article. Disclosure statements are available for viewing upon request., (Copyright© by the American Association of Nurse Anesthetists.)

Background: No studies have examined the long-term benefits of regional anesthesia (RA) for pain management after combat-related injury. The objective of this prospective cohort study was to examine the relationship between RA administration and patient-reported pain-related outcomes among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) service members sustaining a combat-related extremity injury., Methods: Between 2007 and 2013, n=358 American military personnel injured in OEF/OIF were enrolled at two military treatment facilities. Individuals were followed for up to 2 years after injury. Cohorts were defined based on whether participants were administered RA within 7 days after sustaining a combat-related injury, or not. Linear mixed effects models examined the association between RA and average pain intensity. Secondary outcomes included pain relief, pain interference, neuropathic pain symptoms, treatment outcomes related to pain management, and mental health symptoms., Results: Receiving early RA was associated with improved average pain over the first 6 months after injury (β=-0.57; p=0.012) adjusting for injury severity and length of stay at the primary treatment facility. This difference was observed up to 24 months after injury (β=-0.36; p=0.046). Individuals receiving early RA reported greater pain relief, improved neuropathic pain intensity, and higher satisfaction with pain outcomes; however, by 24 months, mean scores did not significantly differ between cohorts., Conclusion: Findings indicate that when administered soon after traumatic injury, RA is a valuable pain management intervention. Future longitudinal studies investigating the timely delivery of RA for optimal pain management in civilian trauma settings are needed., Trial Registration Number: NCT00431847., Competing Interests: Competing interests: None declared., (© American Society of Regional Anesthesia & Pain Medicine 2019. Re-use permitted under CC BY-NC. No commercial re-use. Published by BMJ.)

Background: An increase in infant drops on a postpartum unit prompted a quality improvement project to examine causes and formulate risk reduction strategies. Review of health records revealed that infant drops occurred more frequently when mothers fell asleep holding infants., Methods: A prospective descriptive study was conducted with a convenience sample of 101 postpartum mother-infant dyads. Hourly assessments of maternal sleepiness using the Stanford Sleepiness Scale (SSS) and surveillance of patient rooms were performed during hospitalizations (N = 4,550 observations)., Results: Mothers slept on average 3.7 hours/day (median = 5.0). Sleepiness followed an expected nighttime routine on postpartum day 1 regardless of when mothers arrived on the unit. Peak sleepiness was observed at 04:00 (mean SSS score = 5.3; standard deviation [SD] = 2.6), and mothers were most awake until 18:00 (mean SSS score = 1.9; SD = 1.7). No infant drops occurred during the project; however, 50 participants required at least one intervention or corrective action to address unsafe sleep. Of 1,718 observations of mothers in bed with their infant, there were 35 instances (2.0%) where nurses observed mothers asleep holding their infant., Conclusion: Frequent observations of maternal sleepiness and infant environments may prevent infant drops and provide opportunities for intervening with risk reduction strategies, including education on safe sleep for infants., (Copyright © 2019. Published by Elsevier Inc.)

Alarm fatigue is the most common contributing factor in alarm-related sentinel events. Researchers have demonstrated a 35% overuse of telemetry, a key factor in alarm fatigue. This project evaluates practice patterns for the ordering and discontinuation of telemetry on medical-surgical units. Practice patterns were reviewed to determine if they aligned with the American Heart Association evidence-based practice guidelines for telemetry monitoring and whether the order indication was congruent with the patient's clinical status. Nurse's attitudes and practices related to alarm safety were evaluated., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Delirium, an acute change in cognition and attention not secondary to a pre-existing condition or dementia, affects nearly 40,000 hospitalized older adults in the United States every day. Delirium is associated with increased healthcare costs of $16,303 to $64,421 per patient. To date, no single pharmacological intervention is effective in preventing or treating delirium in critically ill patients. Evidence suggests the alpha-2 agonist, dexmedetomidine, may reduce or prevent delirium. An integrative review examined whether dexmedetomidine was associated with a lower incidence of delirium compared to other analgesic and sedation strategies. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guided this review and 16 publications met quality criteria for inclusion. These studies support that postoperative administration of dexmedetomidine may reduce delirium in patients, particularly following cardiac surgery. Further research is needed to determine the benefits of dexmedetomidine in patients on mechanical ventilation and optimal timing and duration of administration., (Copyright © 2018 Elsevier Inc. All rights reserved.)

: Multimodal analgesia, which combines analgesic drugs from different classes and employs analgesic techniques that target different mechanisms of pain, is recommended in the treatment of acute postoperative and trauma-related pain because its synergistic effect maximizes pain relief at lower analgesic doses, thereby reducing the risk of adverse drug effects. Using a case-based approach, this article reviews various multimodal analgesic therapies used in the treatment of acute pain; discusses their benefits; and summarizes findings from related research, recommendations from evidence-based practice guidelines, and expert consensus reports.

Adverse events secondary to opioid-induced advancing sedation and respiratory depression continue to occur during hospitalizations despite efforts to increase awareness and clinical practice guidelines to address prevention strategies. In 2009, ASPMN surveyed membership on current practices surrounding this topic. ASPMN clinical practice guidelines were then published in 2011. In winter of 2013, ASPMN membership was again surveyed to assess progress in preventing adverse events. This is a report of the follow-up membership survey. In general, monitoring practices are slowly improving over time, but there are many facilities that have not instituted best practices for avoiding adverse events., (Copyright © 2014 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)