Search

Background This was a retrospective chart review of procedural pain assessments and interventions during arterial catheter insertion in an adult neurological intensive care unit where patients with impaired consciousness are common. Overall, pain assessment was well documented (100%) by Registered Nurses, but not specific to arterial line insertion. Nurse practitioners commonly placed arterial lines and used local analgesia in over 75% of the documented procedures. Aims The purpose of this study was to examine healthcare providers’ pain-related practices documented during arterial catheter insertion, one of the most painful procedures in a neurological intensive care unit. Secondary purposes were determining whether patient characteristics, procedure-related factors, or provider licensure were associated with pain assessment or procedural pain interventions. Design A retrospective records review design was used. Methods 120 electronic patient medical records were reviewed during a one-year period. Results 100 charts met inclusion criteria. Nurses assessed all pain within 4 hours following the procedure in all charts but procedure-specific pain assessments were documented in 4% of charts. Pain-related interventions for arterial line insertion were local analgesic (76% of charts) and other procedure-specific interventions (10%). Significant associations occurred between procedure specific pain assessments and decreased number of insertion attempts (p = .006) and between pain interventions and number of insertion attempts (p = .003). No provider documented procedural pain assessment regarding arterial line insertion. Associations between patient characteristics and pain interventions were significant for patient ethnicity (F = 8.967, p = .007). Conclusions Overall pain assessment was documented (100%) but not specific to arterial line insertion. Although arterial line insertion can be extremely painful, patients were rarely assessed for such pain by any clinician; 14% did not receive any preprocedural analgesia. Clinical Implications The lack of procedural pain assessment in this vulnerable population indicates a need for increased pain management education for clinicians and further investigations to determine whether sufficient analgesia is provided to reduce procedural pain during arterial line insertion.

Integration of flexible visitation into a large health system requires concentrated effort. Evaluating impact on patient, family, and staff outcomes is important to facilitate changes and ensure visiting policy success. The medical intensive care unit staff participated in a collaborative quality improvement effort to encourage flexible visitation. The integration of flexible visitation spanned an 18-month period, timed to accompany a transition to a new setting with rooms designed to support visitor presence. This article details these efforts, outcomes, and important gaps for future work evaluating integration of flexible visitation in critical care.

Background Standards for interfacility transport in the United States recommend that each transport request be triaged to ensure that each patient is transported by an appropriate mechanism and by the appropriate clinicians in order to meet the patient's intratransport needs. No instrument currently exists to meet that need. The Transport Triage Tool, a novel instrument, has been designed to determine the clinician (paramedic, registered nurse, or advanced practice registered nurse) who will best meet the patient's needs during transport. Objective To assess psychometric elements-that is, validity and reliability-of the Transport Triage Tool when used by health care professionals in determining which clinician is appropriate for interfacility transport. Methods A 3-step process was used to initially evaluate the reliability and validity of this tool when assigning a lead clinician during transport. Content and predictive validity were evaluated. Both intrarater and interrater agreement were used to examine reliability. Results Predictive validity was supported by an area under the receiver operating characteristic curve of 0.847 and a Youden index of 0.31. Percentage agreement and Cohen κ were reasonable across all periods of testing. Conclusions The Transport Triage Tool has acceptable predictive validity and reliability; however, this preliminary evaluation indicates that further refinement is needed. Large tertiary centers that offer variations in transport team composition may be able to use the Tool in its present form to train and evaluate individuals who make decisions regarding interfacility transport, although additional testing and evaluation are recommended.

A source of insecurity among new physicians and new nurses is communicating and managing acute changes in patient condition. Mock page programs are an effective method for teaching communication and clinical decision-making skills to medical students. Joint participation in a mock page program provides a unique opportunity for medical and nursing students to practice communication, collaboration, and clinical decision-making in a low-risk learning environment. The purpose of this pilot study was to examine attitudes toward communication and collaboration among medical and nursing students after participation in a mock page program.Twenty-four medical students participating in a surgical residency preparatory course were paired with 24 senior level nursing students. Over a period of 3 weeks, nursing students delivered 5 mock pages to the medical students. Mock pages consisted of peer-reviewed, prescripted scenarios depicting patients experiencing common postoperative complications. A 12-question survey measuring attitudes toward communication and collaboration between physicians and nurses was administered prior to delivery of the first page and after delivery of the last page. A dependent sample t test was used to perform item analysis.Individual item analysis of medical student surveys indicated significant improvement in attitudes toward communication and collaboration with nurses in 12 out of 12 survey items (p0.05). Individual item analysis of nursing student surveys indicated significant improvement in attitudes toward communication and collaboration with physicians in 6 out of 10 survey items (p0.05). There was no decline in attitudes among any of the survey items.The results from this study suggest that an interprofessional mock page program improves attitudes toward communication and collaboration between medical and nursing students. This program has the potential to improve the quality of education and increase confidence among medical and nursing students as they prepare for their professional roles.

Item does not contain fulltext OBJECTIVE: To update and expand the 2013 Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU. DESIGN: Thirty-two international experts, four methodologists, and four critical illness survivors met virtually at least monthly. All section groups gathered face-to-face at annual Society of Critical Care Medicine congresses; virtual connections included those unable to attend. A formal conflict of interest policy was developed a priori and enforced throughout the process. Teleconferences and electronic discussions among subgroups and whole panel were part of the guidelines' development. A general content review was completed face-to-face by all panel members in January 2017. METHODS: Content experts, methodologists, and ICU survivors were represented in each of the five sections of the guidelines: Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption). Each section created Population, Intervention, Comparison, and Outcome, and nonactionable, descriptive questions based on perceived clinical relevance. The guideline group then voted their ranking, and patients prioritized their importance. For each Population, Intervention, Comparison, and Outcome question, sections searched the best available evidence, determined its quality, and formulated recommendations as "strong," "conditional," or "good" practice statements based on Grading of Recommendations Assessment, Development and Evaluation principles. In addition, evidence gaps and clinical caveats were explicitly identified. RESULTS: The Pain, Agitation/Sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) panel issued 37 recommendations (three strong and 34 conditional), two good practice statements, and 32 ungraded, nonactionable statements. Three questions from the patient-centered prioritized question list remained without recommendation. CONCLUSIONS: We found substantial agreement among a large, interdisciplinary cohort of international experts regarding evidence supporting recommendations, and the remaining literature gaps in the assessment, prevention, and treatment of Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) in critically ill adults. Highlighting this evidence and the research needs will improve Pain, Agitation/sedation, Delirium, Immobility (mobilization/rehabilitation), and Sleep (disruption) management and provide the foundation for improved outcomes and science in this vulnerable population.

BackgroundDetection of brain-specific miRNAs in the peripheral blood could serve as a surrogate marker of traumatic brain injury (TBI). Here, we systematically identified brain-enriched miRNAs, and tested their utility for use as TBI biomarkers in the acute phase of care.MethodsPublically-available microarray data generated from 31 postmortem human tissues was used to rank 1,364 miRNAs in terms of their degree of brain-specific expression. Levels of the top five ranked miRNAs were then prospectively measured in serum samples collected from 10 TBI patients at hospital admission, as well as from 10 controls.ResultsThe top five miRNAs identified in our analysis (miR-137, miR-219a-5p, miR-128-3p, miR-124-3p, and miR-138-5p) exhibited 31 to 74-fold higher expression in brain relative to other tissues. Furthermore, their levels were elevated in serum from TBI patients compared to controls, and were collectively able to discriminate between groups with 90% sensitivity and 80% specificity. Subsequent informatic pathway analysis revealed that their target transcripts were significantly enriched for components of signaling pathways which are active in peripheral organs such as the heart.ConclusionsThe five candidate miRNAs identified in this study have promise as blood biomarkers of TBI, and could also be molecular contributors to systemic physiologic changes commonly observed post-injury.A FINAL PEER REVIEWED VERSION OF THIS ARTICLE HAS BEEN PUBLISHED IN BRAIN INJURY AT THE FOLLOWING DOI: 10.1080/02699052.2020.1764102There are some notable differences between the analysis presented in this preprint and our final peer-reviewed article. There was a single tissue sample originating from spinal cord that we had classified as a non-brain tissue in our original analysis outlined in this preprint. Because the composition of spinal cord and brain are highly similar in terms of gene expression, classifying this sample as a non-brain tissue dramatically reduced the levels of brain enrichment observed in the analysis. Because brain and spinal cord are molecularly highly similar, but technically distinct anatomical structures, we simply decided to exclude this sample from our final analysis published in Brain Injury to avoid confounds. The top 5 miRNAs identified in our original analysis still fell within the top 7 of this final analysis. In addition, the final analysis identified two additional miRNAs which could be candidate biomarkers based on levels of brain enrichment.The final article published in Brain Injury also reports an additional confirmatory tissue specificity analysis performed in a second independent dataset, as well as additional analysis examining the brain specificity of several notable previously proposed miRNA TBI biomarkers, which is not described in this preprint.

This report is a secondary analysis of data from a larger study of a nurse-led early therapeutic mobility intervention among patients receiving mechanical ventilation. This analysis evaluated whether intervention frequency or intensity was associated with pain or fatigue. Frequency was defined as once-daily versus twice-daily interventions. Intensity was defined as low (in-bed activities) or moderate (out-of-bed activities). Thirty-nine patients self-reported pain and fatigue immediately before and after the intervention. Neither pain nor fatigue increased significantly (mean increase

Aims and objectives This project used the Patient Reported Outcomes Measurement Information System (PROMIS) tools to evaluate heart failure patient's experiences of dyspnea, fatigue, and physical mobility during initiation and up titration of drugs in an outpatient setting. Background Investigating patient reported outcome may improve adherence to GDMT. Theoretical support for this study is found in the University of California, Theory of Symptom Management. Design Exploratory, repeated measures design. Methods Patients (n = 21) completed three PROMIS questionnaires for dyspnea, fatigue and physical mobility when GDMT was started or up titrated, and again at a follow up appointment within 30 days (+/− 14 days) of the baseline measures. Patients were asked open- ended queries regarding the usefulness of these questionnaires in identifying and managing symptoms. Provider input was sought on usefulness of the tools in clinical practice and decision making. Results Dyspnea change scores significantly decreased (p = .001), physical mobility scores significantly increased (p = .017), and fatigue scores did not change (p = .319). Duration of HF diagnosis was associated with dyspnea change scores. Patients reported PROMIS tools were easy to use, while providers felt the tools were easy for patients to use but were too long and time intensive for usual office practice. Conclusions Dyspnea and physical mobility improved with up titration of GDMT but fatigue did not change. Relevance to clinical practice PROMIS tools could be helpful in tracking selected symptom changes during GDMT HF medication initiation or up titration for HF management if reformulated into shorter format.

Aims and objectives To examine what occurs after a recorded observation of at least one abnormal vital sign in the emergency department. The aims were to determine how often abnormal vital signs were recorded, what interventions were documented, and what factors were associated with documented follow-up for abnormal vital signs. Background Monitoring quality of care, and preventing or intervening before harm occurs to patients are central to nurses’ roles. Abnormal vital signs have been associated with poor patient outcomes and require follow-up after the observation of abnormal readings to prevent patient harm related to a deteriorating status. This documentation is important to quality and safety of care. Design Observational, retrospective chart review. Methods Modified Early Warning Score was calculated for all recorded vital signs for 195 charts. Comparisons were made between groups: (1) no abnormal vital signs, (2) abnormal vital sign present, but normal Modified Early Warning Score and (3) critically abnormal Modified Early Warning Score. Results About 62·1% of charts had an abnormal vital sign documented. Critically abnormal values were present in 14·9%. No documentation was present in 44·6% of abnormal cases. When interventions were documented, it was usually to notify the physician. The timing within the emergency department visit when the abnormalities were observed and the degree of abnormality had significant relationships to the presence of documentation. Conclusions It is doubtful that nurses do not recognise abnormalities because more severely abnormal vital signs were more likely to have documented follow-up. Perhaps the interruptive nature of the emergency department or the prioritised actions of the nurse impacted documentation within this study. Further research is required to determine why follow-up is not being documented. Relevance to clinical practice To ensure safety and quality of patient care, accurate documentation of responses to abnormal vital signs is required.

Objective: Investigate the feasibility of a nurse-led mobility protocol and compare the effects of once- versus twice-daily episodes of early therapeutic mobility (ETM) and low- versus moderate-intensity ETM on serum biomarkers of inflammation and selected outcomes in critically ill adults. Design: Randomized interventional study with repeated measures and blinded assessment of outcomes. Setting: Four adult intensive care units (ICUs) in two academic medical centers. Subjects: Fifty-four patients with > 48 hr of mechanical ventilation (MV). Intervention: Patients were assigned to once- or twice-daily ETM via sealed envelope randomization at enrollment. Intensity of (in-bed vs. out-of-bed) ETM was administered according to protocolized patient assessment. Measurements: Interleukins 6, 10, 8, 15, and tumor necrosis factor-α were collected from serum before and after ETM; change scores were used in the analyses. Manual muscle and handgrip strength, delirium onset, duration of MV, and ICU length of stay (LOS) were evaluated as patient outcomes. Main Results: Hypotheses regarding the inflammatory biomarkers were not supported based on confidence intervals. Twice-daily intervention was associated with reduced ICU LOS. Moderate-intensity (out-of-bed) ETM was associated with greater manual muscle test scores and handgrip strength and reduced occurrence of delirium. Conclusion: Findings from this study suggest that nurses can provide twice-daily mobility interventions that include sitting on the edge of the bed once patients have a stable status without altering a pro-inflammatory serum biomarker profile.

Successful hemodialysis treatments for patients with renal failure depend on patient adherence to prescribed treatment regimens. Lack of adherence may contribute to patient discomfort between hemodialysis treatments. This article reports a descriptive, correlational feasibility study that utilized Kolcaba's Comfort Theory as a framework. The purpose of the study was to determine a potential relationship between comfort and fluid retention (a proxy for adherence) in adults with end stage renal disease receiving hemodialysis. A convenience sample of 51 patients receiving hemodialysis was studied. Comparisons of patient weight gain between hemodialysis treatment sessions measured fluid retention by proxy. Results indicated no significant relationship between the variables of comfort and adherence to fluid restrictions. However, this finding has potential to support clinical practice to minimize weight gain to sustain comfort. Awareness of comfort as a consideration for adherence to prescribed treatment regimens may help nurses coach individuals to improve treatment adherence.

Author(s): Devlin, John W; Skrobik, Yoanna; Gelinas, Celine; Needham, Dale M; Slooter, Arjen JC; Pandharipande, Pratik P; Watson, Paula L; Weinhouse, Gerald L; Nunnally, Mark E; Rochwerg, Bram; Balas, Michele C; van den Boogaard, Mark; Bosma, Karen J; Brummel, Nathaniel E; Chanques, Gerald; Denehy, Linda; Drouot, Xavier; Fraser, Gilles L; Harris, Jocelyn E; Joffe, Aaron M; Kho, Michelle E; Kress, John P; Lanphere, Julie A; McKinley, Sharon; Neufeld, Karin J; Pisani, Margaret A; Payen, Jean-Francois; Pun, Brenda T; Puntillo, Kathleen A; Riker, Richard R; Robinson, Bryce RH; Shehabi, Yahya; Szumita, Paul M; Winkelman, Chris; Centofanti, John E; Price, Carrie; Nikayin, Sina; Misak, Cheryl J; Flood, Pamela D; Kiedrowski, Ken; Alhazzani, Waleed

There are limited data describing mobility interventions provided to patients with femoral catheters. The purpose of this study was to examine the incidence of femoral catheter related adverse effects during physical therapy (PT) sessions in a cardiovascular intensive care unit (ICU).This was a prospective, observational study and included patients with at least one femoral catheter. Data were collected after each PT session.There were 77 subjects with a total of 92 femoral catheters (50 arterial, 15 central venous, and 27 dialysis) treated. A total of 210 separate PT sessions occurred with 630 mobility activities including sitting on side of bed, standing at the bedside, transfers to stretcher chair or regular chair, and walking. There were no catheter related mechanical or thrombotic complications during any of the PT sessions.Physical therapy sessions, including standing and walking were feasible and safe in cardiovascular ICU patients with femoral catheters who met the criteria for mobility interventions. The results from this study support the hypothesis that early mobilization in patients with femoral catheters is important to minimize functional decline and provide evidence that the presence of femoral catheters alone should not be a reason to limit progressive mobility interventions.

Human skeletal muscles are continually remodeled to match the function required of them. Diameter, strength, and vascular supply are altered when a muscle group experiences contraction and resistance. The purpose of this article is to describe selected muscle signaling pathways that contribute to muscle remodeling. Multiple factors affect the cellular and molecular remodeling of muscles and at least 2 of them-exercise and protein/calorie delivery-are under the direct care of intensive care unit (ICU) clinicians. Activating signaling pathways may promote preservation of muscle mass and function. Interventions to prevent muscle atrophy have potential to reduce ICU-acquired weakness and positively affect quality of life in survivors after ICU hospitalization. Exploring information generated by genomic and proteomic investigations about muscle signaling pathways can help the ICU clinician evaluate the benefits and risks of interventions to maintain muscle health early in critical illness.

The purpose of this review was to summarize the findings of published reports that investigated quality-related outcomes and emergency department (ED) crowding. Of 276 data-based articles, 23 reported associations between patient outcomes and crowding. These articles were grouped into 3 categories: delay in treatment, decreased satisfaction, and increased mortality. Although these studies suggest that crowding results in poor outcomes, it is possible that other factors such as nursing care contribute to these adverse outcomes. Nursing care has been shown to contribute to both positive and negative patient outcomes in other settings. Building an understanding of how ED crowding affects the practice of the emergency nurse is essential to examining how nursing care, surveillance, and communication impact outcomes of emergency patients. Investigation into nurse-sensitive quality indicators in the ED has potential to develop strategies that deliver high quality of care, regardless of crowded conditions.

Objective This study examined therapeutic mobility activity, and investigated whether serum levels of inflammatory biomarkers interleukin (IL)-6 and IL-10 varied between periods of rest and activity. Methods This observational, exploratory study took place in a medical intensive care unit and in stepdown units at an urban, academic medical center managed by intensivists. Our sample included 17 adults with exacerbations of chronic obstructive pulmonary disease (COPD). Results Our results indicate that activity can occur for about 20 minutes, early during a hospitalization, among critically ill adults with COPD exacerbations, and activity can progress safely over 2 days in an intensive-care or stepdown setting. Physical activity was low in intensity, as measured by actigraphy. Conclusion Although no significant differences were evident between serum inflammatory biomarkers at rest vs after activity in this small sample, trend-related data indicate that low-intensity activity has the potential to alter the inflammatory profile of hospitalized COPD adults.

Obese patients in the ICU present unique challenges to the health care team and specific challenges to nurses. This article reviews the science and art of resource use for obese patients in the ICU. Staff nurses and advanced practice nurses can make important contributions in evaluating optimal resource use and improving outcomes in this population of vulnerable patients.

Bed rest is a common intervention for critically ill adults. Associated with both benefits and adverse effects, bed rest is undergoing increasing scrutiny as a therapeutic option in the intensive care unit. Bed rest has molecular and systemic effects, ultimately affecting functional outcomes in healthy individuals as well as in those with acute and critical illnesses. Using empirical sources, the purpose of this article was to describe the consequences of bed rest and immobility, especially consequences with implications for critically ill adults in the intensive care unit. This review uses body systems to cluster classic and current results of bed rest studies, beginning with cardiovascular and including pulmonary, renal, skin, nervous, immune, gastrointestinal/metabolic, and skeletal systems. It concludes with effects on muscles, a system profoundly affected by immobility and bed rest.

Two endotracheal tubes (ETTs) are available for use in operative suites for intubation: the Parker Flex-Tip (PFT, Parker Medical) and the standard Mallinckrodt (Covidien). To the authors' knowledge, no study has compared these 2 ETTs with each other when the anesthesia provider uses the GlideScope video laryngoscope (Verathon) for intubation. The purpose of the study was to determine if there are differences related to ease of intubation reported by anesthesia providers who use the PFT tube compared with the standard tube while using the GlideScope. The study was a randomized block intervention design. The sample consisted of 58 observed intubations in an operating room setting. Data analysis was completed with a 2-factor analysis of covariance using 2 covariates. The PFT tube in suboptimal conditions demonstrated a significantly greater ease of intubation, as measured by decreased time for ETT insertion and greater ease of ETT insertion score. The number of redirections at the glottis to intubate the trachea once the glottis was visualized was not statistically different. Based on the findings from this study, anesthesia providers may want to consider the use of the PFT tube when using the GlideScope to promote ease of intubation.

The 2013 American College of Critical Care Medicine/Society of Critical Care Medicine clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit serves as a living example of nurses’ involvement in the development and implementation of professional guidelines. Nurses who served on this guideline-writing panel describe their experiences. Specific examples from the pain, agitation, and delirium guidelines for care are used to explore the roles of the nurse leader, nurse informaticist, staff nurse, and nurse researcher in relationship to guideline implementation.

Although therapeutic activity prevents functional decline and reduces mortality, little is known about typical levels of activity among intensive care unit (ICU) patients. This report of a preliminary study describes typical therapeutic activity and compares the use of two measures of activity in a small sample of chronically critically ill adults. Type, frequency, and duration of therapeutic activity were measured simultaneously with direct observation and actigraphy. The only consistent activity documented was turning (frequency: 3 turns/8 hours; duration: mean average of 11 minutes). Analysis demonstrated acceptable agreement between the two measures of activity for both frequency and duration of therapeutic but not for type of activity. Congruence between measures for duration of activity was also supported. This study provides information for investigators and practitioners who are interested in measuring or implementing therapeutic activity in selected critically ill adults.

This project described prospectively obese, critically ill patients and the resources critical care nurses used to care for these challenging patients. It also examined the relationship between resources used by nurses and patient outcomes, including complications and length of stay. Forty-three participants were enrolled. Patients with a body mass index (BMI) 40 kg/m2 used the majority of equipment and personnel resources and experienced a prolonged length of stay. The most common equipment used was a specialty bed or mattress; the most common complications were related to the pulmonary system. Initial use of multiple resources may indicate a patient at risk for adverse outcomes. Nurses can use findings to anticipate care needs and develop interventions, such as optimal positioning, to avoid adverse outcomes.

To purchase reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 8092273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. parents to offspring. Commonly, genetics refers to the study of single genes and their traits. Genetics explains how physical characteristics, susceptibility to disease, and even personality and behavior “run” in families. A genome is all the DNA contained in an organism or a cell. Thus, the human genome consists of the approximately 30 000 genes found in human beings. Genomics is the study of how all the genes function, interact, and influence the biology and physical characteristics of living things. Genomic science is used to examine common but complex diseases such as chronic obstructive pulmonary disease, acute coronary syndromes, sepsis, infection, and the conditions that contribute to these and other complex illnesses. With genomic resources, technology, and education, the interaction of multiple genes and environmental factors can be investigated, and individualized treatment can be developed. Chris Winkelman, RN, PhD, CCRN

Hyponatremia commonly occurs in patients with aneurysmal subarachnoid hemorrhage. Two mechanisms have been proposed as causes: syndrome of inappropriate anti-diuretic hormone and cerebral salt wasting. Physical examination and laboratory results can assist a clinician in identifying which mechanism is responsible and thus determine proper treatment. When hyponatremia is treated promptly and appropriately, patients' sodium levels return to normal without detrimental effects.

Muscle dysfunction leads to activity intolerance, prolonged hospitalization, and additional days of mechanical ventilation. The etiology of muscle dysfunction in the critically ill patient is multifactoral. Inactivity and inflammation, common phenomena to patients in the intensive care unit, are associated with myopathy and muscle dysfunction. Cytokines are small biological active molecules that regulate inflammation and have a direct effect on muscle wasting. The purpose of this article is to describe selected cytokines (ie, interleukin-1, interleukin-6, interleukin-10, and tumor necrosis factor), explain their role in muscle dysfunction, and explore the role of therapeutic activity as a moderator of muscle dysfunction and cytokine-mediated muscle damage.

Profound muscle weakness during and after critical illness is termed intensive care unit-acquired weakness (ICUAW).To develop diagnostic recommendations for ICUAW.A multidisciplinary expert committee generated diagnostic questions. A systematic review was performed, and recommendations were developed using the Grading, Recommendations, Assessment, Development, and Evaluation (GRADE) approach.Severe sepsis, difficult ventilator liberation, and prolonged mechanical ventilation are associated with ICUAW. Physical rehabilitation improves outcomes in heterogeneous populations of ICU patients. Because it may not be feasible to provide universal physical rehabilitation, an alternative approach is to identify patients most likely to benefit. Patients with ICUAW may be such a group. Our review identified only one case series of patients with ICUAW who received physical therapy. When compared with a case series of patients with ICUAW who did not receive structured physical therapy, evidence suggested those who receive physical rehabilitation were more frequently discharged home rather than to a rehabilitative facility, although confidence intervals included no difference. Other interventions show promise, but fewer data proving patient benefit existed, thus precluding specific comment. Additionally, prior comorbidity was insufficiently defined to determine its influence on outcome, treatment response, or patient preferences for diagnostic efforts. We recommend controlled clinical trials in patients with ICUAW that compare physical rehabilitation with usual care and further research in understanding risk and patient preferences.Research that identifies treatments that benefit patients with ICUAW is necessary to determine whether the benefits of diagnostic testing for ICUAW outweigh its burdens.

The benefits of early mobilization for adult patients in the intensive care unit (ICU) are reduced length of ICU and hospital stays, fewer readmissions to the ICU, decreased duration of mechanical ventilation, fewer days of detrimental bedrest, minimal adverse or unsafe events, and improved walking distance. Because there are no available tools to specifically measure mobility status of patients in the ICU setting, there is an urgent need to create a reliable tool that measures and standardizes the assessment of mobility status for these patients. The purpose of this study was to describe the development of this novel ICU-specific tool to assess a patient's mobility status, examine the initial reliability of the tool, and address its clinical application. The Perme ICU Score was quickly and easily administered by physical therapists. Overall, the inter-rater agreement was 94%. A total of six items had kappa values of < .6, and these low scores may have been the result of the procedure to collect inter-rater scores, wherein one rater assisted with the activity while a second rater observed. In order to improve reliability, the authors developed directions to standardize the assessment. The Perme ICU Mobility Score is a tool developed to measure the patient's mobility status starting with the ability to follow commands and culminating in the distance walked in two minutes. Preliminary data suggest that the validity of this tool is supported by expert concurrence, its overall reliability is high, and its clinical use is acceptable.

Today’s health care delivery system relies heavily on interhospital transfer of patients who require higher levels of care. Although numerous tools and algorithms have been used for the prehospital determination of mode of transport, no tool for the transfer of patients between hospitals has been widely accepted. Typically, the interfacility transport decision is left to the discretion of the referring provider, who may or may not be aware of the level of care provided or the means of transport available. A need exists to determine the appropriate level of care required to meet the needs of patients during transport. The American Association of Critical-Care Nurses (AACN) Synergy Model for Patient Care is a patient-centered model that focuses on optimizing patient care by matching the characteristics of the patient with the competencies of the nurse. This model shows significant promise in providing the theoretical backing to guide the decision on the level of care necessary to complete interfacility transfers safely and effectively. This article describes a new tool inspired by the AACN Synergy Model for Patient Care to determine the appropriate level of care required for interfacility transport.

As genomic health care becomes commonplace, nurses will be asked to provide genomic care in all health care settings including acute care and critical care. Three common cardiac conditions are reviewed, Marfan syndrome, bicuspid aortic valve, and hypertrophic cardiomyopathy, to provide acute care and critical care nurses with an overview of these pathologies through the lens of genomics and relevant case studies. This information will help critical care nursing leaders become familiar with genetics related to common cardiac conditions and prepare acute care and critical care nurses for a new phase in patient diagnostics, with greater emphasis on early diagnosis and recognition of conditions before sudden cardiac death.

Background: Motivations and attitude are known to influence goal directed activity such as adoption of new behaviors in teaching. Accordingly, understanding nurse educators’ motivation and attitudes toward evidence-based teaching is a critical step to successfully transforming the faculty’s culture to use best practices in nursing education. The aim of this study was to examine the effect of workshop, on Egyptian nurse educators' motivation and attitude toward evidence-based teaching over time. Methods: Quasi-experimental design with three periods of data collection: a pre-test and two post-test periods at the School of Nursing, Zagazig University, Egypt. A convenience sample of nurse faculties who were invited to attend a one-day workshop was used. There were no exclusion criteria. Four tools were used: the Demographic form, the Follow-up form, The Situational Motivation Scale (SIMS), and the Evidence-Based Nursing Attitude Questionnaire (EBNAQ). Results: A total of 48 nurse faculty agreed to participate in the study; they were female with a mean age of 30 years and an average of 5.5 years of experience in academic setting. Half of the participants had master’s degree or higher. There were significant differences between the pre-, post- and follow-up scores in three of the motivation subscales. Regarding “lack of motivation”, these scores and scores of attitude toward evidence based teaching did not change over time. There was a significant difference in the external regulation score comparing faculty subgroups (i.e., implementers versus non- implementers). Conclusions: A workshop about best practices in nursing education fostered increased intrinsic motivation, identified regulation, and external regulation immediately and changes were sustained over a three month period. A total of 23% of workshop participants implemented an evidence-based education strategy after the workshop, promoting best practices in nursing education.

Critical care, defined as the diagnosis and management of life-threatening conditions that require close or constant attention by a group of specially trained health professionals, is inherent to the practice of cardiovascular medicine. The demand for cardiovascular critical care is increasing with the aging of the population and is reflected by trends in the use of critical care in general.1 Between 2000 and 2005, although the total number of hospital beds in the United States declined by 4.2%, the number of critical care beds increased by 6.5% and the annual costs attributed to critical care increased by 44%, representing 13.4% of hospital costs.2 Projections for the next 15 years suggest that the need for critical care will increase markedly in the United States and globally.1,3–5 For example, in Canada, a 57% increase in the need for critical care beds is anticipated during that period.5 Concurrent with increases in demand, the medical demographics of general and cardiac critical care have evolved toward a patient population with an increasing number of comorbid medical conditions who require more prolonged and more technologically sophisticated invasive support. As a result, the delivery of critical care is advancing substantially in its complexity. Moreover, accumulating evidence has indicated that outcomes are better when critical care is provided by specially trained providers in a dedicated intensive care unit (ICU).6–9 In the context of this evolution, provision of optimal care in the contemporary cardiac ICU (CICU) presents a different set of challenges and requires an expanded set of skills compared with 10 years ago. Cardiovascular medicine has lagged behind other medical disciplines that have met the “critical care crisis”4 with ICU-focused innovations in organization, training, and quality improvement. Therefore, the American Heart Association Council on Cardiopulmonary, Critical …

Pressure-related intact discolored areas of skin (PRIDAS) are generally described as an area of nonblanching erythema (Stage I pressure ulcer) or deep tissue injury (DTI), but the validity of these definitions has not been tested. Preclinical studies and forensic observations have shown that skin temperature may help identify nonviable tissue. To investigate the effect of temperature difference between a PRIDAS and its adjacent intact skin and the subsequent development of skin necrosis, an observational, retrospective, correlational study was conducted. Data from all acute care hospital patients with an observed PRIDAS who received a skin integrity consult, including a skin temperature measurement of a PRIDAS site, were abstracted to ascertain if PRIDAS temperature correlated with the development of skin necrosis after 7 to 14 days and to examine the effect of additional patient variables on the progression or resolution of a PRIDAS. Skin temperatures were measured using a commercial, hand-held, infrared thermography camera, and the presence or absence of capillary refill was documented. Among the 85 patients studied, the difference between PRIDAS temperature and adjacent skin ranged from -3.2 ̊ C. to +3.0 ̊C. Of the 55 PRIDAS with a lower temperature at baseline than adjacent skin ("cool", average -1.2 ̊ C), 29 progressed to necrosis, compared to one of 30 PRIDAS with a higher temperature than adjacent skin ("warm", average + 1.2 ̊ C) (P0.001). After adjusting for patient age, skin color, and PRIDAS site, the cool PRIDAS were 31.8 times more likely to progress to necrosis than the warm PRIDAS. Combining the presence/absence of capillary refill and PRIDAS temperature, 0% of 26 patients with signs of blanching and a warm PRIDAS versus 65% of 26 patients with a nonblanching and cool PRIDAS developed skin necrosis (P0.001, Fisher exact test for the difference between the two combined values). Research examining the delayed appearance of DTI and large, multicenter, prospective validation studies are warranted. The current National Pressure Ulcer Advisory Panel definition of a Stage I pressure ulcer needs to be amended to reflect the strong relationship to DTI development.

Introduction Vital signs are an important component of the nursing assessment and are used as early warning signs of changes in a patient's condition; however, little research has been conducted to determine how often vital signs are monitored in the emergency department. Additionally, it has not been determined what personal, social, and environmental factors affect the frequency of vital sign monitoring. The purpose of this study was to examine what factors may influence the time between recording vital signs in the emergency department. Methods We performed a descriptive, retrospective chart review of 202 randomly selected adult ED patients' charts from representative times to capture a variety of ED levels of occupancy in an urban, Midwestern, teaching hospital. Descriptive and hierarchical regression analyses were used. Results The strongest predictor of the increased time between vital signs from the personal health factors was lower patient acuity (Emergency Severity Index). This relationship remained strong even when social factors and environmental factors were included. Increased length of stay and fewer routes of medications also had significant relationships to the increased time between vital sign monitoring. Discussion These findings are clinically important because greater time between vital sign recordings can lead to errors of omission by not detecting changes in vital signs that could reveal changes in the patient's condition. The findings of this study provide direction for future research focusing on determining whether higher frequency of vital signs surveillance contributes to higher quality care and linking quality of care to missing vital signs/inadequate monitoring.

The knowledge and performance of hemodialysis nursing staff at Zagazig University Hospitals, Egypt, were evaluated using a quasi-experimental design. Participants received an educational program developed from international standards and national guidelines. The number of nurses who achieved satisfactory knowledge and performance scores increased significantly post-intervention, and were sustained for three months after the intervention. A strong, positive correlation was also found between the participants' knowledge and their performance.

There have been tremendous advances in the diagnosis and treatment of increased intracranial pressure in the past decade. The author presents a review of the pathophysiology of intracranial hypertension, incorporating recent data from neuroscience research. Additional investigations that have implications for the nursing care of patients with actual or potential intracranial pressure also are described.

Is it safe for patients with pulmonary artery catheters inserted via the jugular or subclavian vein to stand up? Do you have any information on ambulating patients with femoral arterial catheters? Some of our patients have femoral arterial catheters after open heart surgery, and the surgeon says to ambulate them with the catheters in place. Although this makes me uncomfortable, I cannot find literature to support or not support this. I do not see any available standards or articles related to safety of ambulation with small-gauge (20 gauge) “soft” femoral catheters. It seems that most institutions have no policy. I refuse to get my patient out of bed with a femoral arterial catheter but often have patients with orders to do so. My concern is related to fibrin clots that may form around the catheter, especially because of its length (usually 20 cm). Valid or not?