nursing journals abstracts

8/12/2019 Nursing Journals abstracts

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Impact of Nursing Staffing on Patient Outcomes in Intensive Care Unit

Background: The impact of nursing care on patient outcomes is not well understood. The objective of

this study is to assess the effects of nursing care hours per patient day, nursing skill mix, and nurse

turnover on central line-associated bloodstream infection (C!"#$% rates, length of stay (&#%, andmortality in the context of intensive care units ($C's% using interventions to reduce bloodstream

infections and improve patient safety, teamwork and interdisciplinary communication.

Results: ursing care hours per patient day greater than )* hours was associated with lower C!"#$rates. $ncreasing nursing hours per patient day was also associated with shorter &#, with the

strongest relationship where nursing hours per patient day was lower (+ )* hours compared to )*

hours%. ! igher skill mix was associated with shorter &# but higher C!"#$ rates. e found no

significant relationships of nursing turnover with any outcome, or between any nursing variables andmortality.

Conclusions: &ur findings suggest that nursing care hours per patient day and nursing skill mix

significantly contribute to C!"#$ prevention and &# in the $C' setting.

Impact of Intensive Care Unit Physician on Care Processes of Patients with Severe Sepsis in

Teaching Hospitals

!bstract

Objective: The purpose of the study was to investigate associations among intensive care

unit ($C'% staffing and care processes in patients with severe sepsis.

Results: $C's were classified as high- or low-intensity based on policies regarding theresponsibilities of intensivists. There were no differences in baseline patient characteristics

between the $C' groups. $n the high-intensity group, $C' stay for survivors was about two

days shorter and hospital stay was significantly shorter by three days. /ajority of patientshad high rates of enteral feeding0 however, the high-intensity group had significantly earlier

initiation of enteral feeding and a significantly shorter duration of mechanical ventilation. !

shorter duration of mechanical ventilation was significantly associated with the $C'

structure.

Conclusions: The results showed an association between $C' physician and processes ofintensive care, and high-intensity $C' was aggressive in mechanical ventilation in patientswith severe sepsis.



Continuous STSegment !onitoring in the

Intensive Care Unit

Cardiac monitoring of critically ill patients enables 5 basic features to be detected@ rateabnormalities, rhythm disturbances, and ischemic patterns. hen it was developed, continuous

computeri:ed #T-segment monitoring proved an invaluable resource for detecting ischemia incritically ill cardiac patients. Considered a technological bonus if instituted correctly, this

essential device for detection of myocardial ischemia is underused in the 'nited #tates.6 Axperts

in the field of electrocardiographic (ACB% monitoring are currently advocating for continuous#T-segment monitoring for detection of silent myocardial ischemia (#/$% in all areas where

patients undergo cardiac monitoring because #T-segment monitoring is a simple, inexpensive,

and noninvasive means of providing valuable diagnostic information.)

Therefore, in this article, we analy:e and interpret the research studies behind the

recommendations in the )**1 !!C practice alert on #T-segment monitoring. The intent is to provide critical care clinicians with evidence-based rationales to substantiate revisions of current

monitoring practices and to provide realistic strategies for implementation of new practices.

Skilled Cardiac !onitoring at the Bedside:

"n "lgorithm #or Success

The !merican !ssociation of Critical-Care urses (!!C% posted ) practice alerts to addressissues in cardiac monitoring in )**7 and updated them in !pril )**1.6,) The alerts addressed )

main reasons for use of cardiac bedside monitoring. The first reason is to detect and provide

early intervention for episodes of myocardial ischemia and injury.5,7 Correct ACB lead selectionis crucial for detection of these episodes.6,8 ; 4 hen the correct lead or leads are used, #T-segment

monitoring provides important information for patient care, provided alarms are set

appropriately.

"ecause aggressive early treatment improves outcomes in patients who have myocardialischemia and injury, #T-segment monitoring should be used by all nurses who work in areas

with cardiac monitoring.6,5 ; <,6*,66 The second reason for cardiac bedside monitoring is to detect

serious dysrhythmias that may re>uire treatment. $f patients are not monitored by using therecommended lead for dysrhythmia interpretation, nurses and physicians correctly diagnose a

wide ?# tachycardia only 57= of the time, and erroneous interpretation can lead to

inappropriate treatment.8

The !!C practice alerts6,) identified expected practice for monitoring #T-segments anddysrhythmias. 2uring practice discussions in committees and at the bedside, some nurses at

/ayo Clinic, ?ochester, /innesota, remarked that they did not understand application of the

http://ccn.aacnjournals.org/content/30/5/33.full#ref-1












































concepts covered in the alerts. The ACB lead monitoring algorithm was developed to provide a

tool to assist bedside nurses in combining the ) concepts.

NurseLed Im$lementation o# a Sa#e and%##ective Intravenous Insulin &rotocol in a

!edical Intensive Care Unit

Background ?ecent evidence has linked tight glucose control to worsened clinical outcomes

among adults in intensive care units.

Objective To evaluate the effectiveness and safety of a nurse-led intravenous insulin protocol

designed to achieve conservative blood glucose control in patients in a medical intensive careunit.

!ethods ! nurse-led intravenous insulin protocol was developed, targeting blood glucose levels

at 66* to 674 mgDd. ypoglycemia was defined as a blood glucose level less than <* mgDd.Eatients admitted to the medical intensive care unit who re>uired an insulin infusion were

enrolled in the study. "lood glucose levels in those patients were compared with levels in 685

historical control patients admitted to the unit in the 6) months before the protocol wasimplemented who re>uired an insulin infusion.

Results inety-six patients were enrolled and treated with the protocol. The protocol and control

groups had similar characteristics at baseline. /ore measurements in the protocol group than inthe control group (79.5= vs 59.6=, P +.**6% were within the target glucose range (66*;674mgDd%. yperglycemia (blood glucose )** mgDd% occurred less often in the protocol group

than in the control group (67.1= vs )*.6=, P F.**5%. ypoglycemic events (blood glucose +<*

mgDd% also occurred less often in the protocol group (*.*<= vs *.15=, P +.**6%.

&atient Satis#action and 'ocumentation o#

&ain "ssessments and !anagement "#terIm$lementing the "dult Nonverbal &ain

Scale



Background !ccurate assessment and management of pain in critically ill patients who are

nonverbal or cognitively impaired is challenging. o widely accepted assessment tool is

currently in place for assessing pain in these patients.

Objectives To evaluate the effect of implementing a new pain assessment tool in a

traumaDneurosurgery intensive care unit.

!ethods #taff and patient satisfaction >uestionnaires and retrospective chart reviews were used

before and after implementation of the onverbal Eain #cale. The >uestionnaire responses,fre>uency of pain documentation, and amount of pain medication given were compared from

before to after implementation.

Results /ost staff (<1=% ranked the tool as easy to use. $mplementation of the tool increased

staff confidence in assessing pain in nonverbal, sedated patients (8<= before vs 16= afterimplementation, P F .*)% and increased the number of pain assessments documented by the

nursing staff for noncommunicative patients per day in the intensive care unit ().) before vs 5.7

after, P

F .*)%. Eatients reported decreased retrospective pain ratings (1.8 before vs <.) after, P

F .*7% and a trend toward a decrease in the time re>uired to receive pain medication (51= before

vs 6*= after re>uiring G8 minutes to receive medication, P F .*9%.

Conclusions $mplementation of the onverbal Eain #cale in a critical care setting improved

patients3 ratings of their pain experience, improved documentation by nurses, and increasednurses3 confidence in assessing pain in nonverbal patients.

Clinical %##ectiveness o# a Critical CareNursing Outreach Service in (acilitating

'ischarge (rom the Intensive Care Unit

Background $mproved discharge planning and extension of care to the general care unit for patients transferring from intensive care may prevent readmission to the intensive care unit and

prolonged hospital stays. /orbidity, mortality, and costs increase in readmitted intensive care

patients.

Objectives To evaluate the clinical effectiveness of a critical care nursing outreach service infacilitating discharge from the intensive care unit and providing follow-up in general care areas.

!ethods ! before-and-after study design (with historical controls and a 9-month prospective

intervention% was used to ascertain differences in clinical outcomes, length of stay, and

costDbenefit. Eatients admitted to intensive care units in 5 adult teaching hospitals were recruited.The service centered on follow-up visits by specialist intensive care nurses who reviewed and



assessed patients who were to be or had been discharged to general care areas from the intensive

care unit. Those nurses also provided education and clinical support to staff in general care areas.

Results $n total, 6758 patients were discharged during the 9-month prospective period. ength ofstay from the time of admission to the intensive care unit to hospital discharge ( P F .18%,

readmissions during the same hospital admission (8.9= vs 8.7=, P

F .15%, and hospital survival( P F .1*% did not differ from before to after the intervention.

Conclusions !lthough other studies have shown beneficial outcomes in !ustralia and the 'nitedHingdom, we found no improvement in length of stay after admission to the intensive care unit,

readmission rate, or hospital mortality after a critical care nursing outreach service was

implemented.

O$timi)ing Nutrition in Intensive CareUnits: %m$o*ering Critical Care Nurses to

Be %##ective "gents o# Change

O!servational studies have consistently revealed wide variation in nutritional practices across

intensive care units and indicated that the provision of ade"uate nutrition to critically ill patients

is su!optimal# To date$ the potential role of critical care nurses in implementing nutritional

guideline recommendations and improving nutritional therapy has received little consideration#

%actors that influence nurses& nutritional practices include the lac' of guidelines or conflicting

evidence(!ased recommendations pertaining to nurses& practice$ strategies for implementingguidelines that are not tailored to !arriers nurses face when feeding patients$ strategies to

communicate !est evidence that do not capitali)e on nurses& preference for see'ing information

through social interaction$ prioriti)ation of nutrition in initial and continuing nursing education$

and a lac' of interdisciplinary team colla!oration in the intensive care unit when decisions on

how to feed patients are made# %uture research and "uality improvement strategies are re"uired

to correct these deficits and successfully empower nurses to !ecome nutritional champions at

the !edside# Using nurses as agents of change will help standardi)e nutritional practices and

ensure that critically ill patients are optimally fed#



Communication b+ Nurses in the Intensive

Care Unit: ,ualitative "nal+sis o# 'omains

o# &atientCentered CareBackground igh->uality communication is a key determinant and facilitator of patient-centered care. urses engage in most of the communication with patients and patients3 families

in the intensive care unit.

Objective To perform a >ualitative analysis of nurses3 communications.

!ethods Athnographic observations of 568 hours of interactions and 85 semistructuredinterviews with 55 nurses were conducted in a )9-bed cardiac-medical intensive care unit in an

academic hospital and a )9-bed general intensive care unit in a Ieterans !ffairs hospital in

Eortland, &regon. Communication interactions were categori:ed into 8 domains of patient-centered care. $nterviews were analy:ed to identify major themes in nurses3 roles and preferences

for communicating with patients and patients3 families within the domains.

Results /ost communication occurred in the domains of biopsychosocial information exchange,

patient as person, and clinician as person. urses endorsed the importance of the domains ofshared power and responsibility and therapeutic alliance but had relatively few communication

interactions in these areas. Communication behaviors were strongly influenced by the nurses3

roles as translators of information between physicians and patients and the patients3 families andwhat the nurses were and were not willing to communicate to patients and patients3 families.

Conclusions Critical care, including communication, is a collaborative effort. 'nderstandinghow nurses engage in patient-centered communication in the intensive care unit can guide future

interventions to improve patient-centered care.

Im$lications o# the Ne* International Se$sis

-uidelines #or Nursing Care

Sepsis is a serious worldwide health care condition that is associated with high mortality rates$despite improvements in the a!ility to manage infection# New guidelines for the management of

sepsis were recently released that advocate for implementation of care !ased on evidence(

!ased practice for !oth adult and pediatric patients# Critical care nurses are directly involved in

the assessment of patients at ris' for developing sepsis and in the treatment of patients with

sepsis and can$ therefore$ affect outcomes for critically ill patients# Nurses& 'nowledge of the

recommendations in the new guidelines can help to ensure that patients with sepsis receive

therapies that are !ased on the latest scientific evidence# This article presents an overview of



new evidence(!ased recommendations for the treatment of adult patients with sepsis$

highlighting the role of critical care nurses

"dmission to the Intensive Care Unit and.ellbeing in &atients .ith "dvanced

Chronic Illness

&ur$ose To describe the association of intensive care with trajectories of functional, emotional,

social, and physical well-being in patients with 5 common advanced illnesses.

!ethods Cross-sectional cohort study of 7) patients admitted to the intensive care unit selectedfrom )6* patients with stage $I breast, prostate, or colon cancer or stage $$$b or $I lung cancer0

ew Jork eart !ssociation class $$$ or $I congestive heart failure0 and chronic obstructive

pulmonary disease with hypercapnea (Eco) G 79 mm g%. #cores on subscales of the Kunctional!ssessment of Chronic $llness Therapy-Beneral survey were measured monthly for 9 months

before and after admission to the intensive care unit and were analy:ed by using the unit

admission date as a point of discontinuous change to illustrate trajectories before and after theadmission.

Results &verall, trajectories of well-being declined sharply after admission to the intensive care

unit. 2eclines in physical, functional, and emotional well-being were statistically significant.

2uring the 9 months after admission, physical, functional, and emotional well-being scorestrended back up to baseline while social well-being scores continued to decline.

Conclusions ell-being trajectories declined sharply after admission to the intensive care unit,

with recovery in the subse>uent 9 months, and may be characteri:ed by common patterns. These

results help to better describe intensive care as a marker for advancing illness in patients withadvanced chronic illness.

%ndTidal Carbon 'io/ide as a !easure o#

Stress Res$onse to Clustered NursingInterventions in Neurologic &atients

Background Buidelines recommend rest periods between nursing interventions for patients witha neurologic diagnosis but do not specify a safe number of interventions.



Results The baseline cohort included 45 patients and the posteducation cohort included 49

patients. Eatients were 76= less likely to receive an inappropriate 'T! rating after the

educational campaign (5)= N5* of 45O baseline vs 64= N61 of 49O, P F .*5%. Eatients withconcurrent mechanical ventilation were more likely to receive an inappropriate 'T! rating in the

baseline cohort (odds ratio, 5*.<0 48= C$, 1.4;6*8.40 P + .**6% and the posteducation cohort

(odds ratio, 68.80 48= C$, 7.6;84.80 P

+ .**6%.

Conclusion The educational campaign decreased the incidence of inappropriate 'T! ratings.

The Critical Care .ork %nvironment and

NurseRe$orted 0ealth Care1"ssociated

In#ectionsBackground Critically ill patients are susceptible to health care;associated infections because oftheir illnesses and the need for intravenous access and invasive monitoring. The critical care

work environment may influence the likelihood of infection in these patients.

Objective To determine whether or not the critical care nurse work environment is predictive of

nurse-reported health care;associated infections.

!ethods ! retrospective, cross-sectional design was used with linked nurse and hospital surveydata. urses assessed the critical care work environment and provided the fre>uencies of

ventilator-associated pneumonias, urinary tract infections, and infections associated with centralcatheters. ogistic regression models were used to determine if critical care work environmentswere predictive of nurse-reported fre>uent health care;associated infections, with controls for

nurse and hospital characteristics.

Results The final sample consisted of 5)6< critical care nurses in 5)* hospitals. Compared with

nurses working in poor work environments, nurses working in better work environments were59= to 76= less likely to report that health care;associated infections occurred fre>uently.

Conclusion ealth care;associated infections are less likely in favorable critical care work

environments. These findings, based on the largest sample of critical care nurses to date,

substantiate efforts to focus on the >uality of the work environment as a way to minimi:e thefre>uency of health care;associated infections.



&redictive 2alidit+ o# the Braden Scale #or

&atients in Intensive Care Units

Background Eatients in intensive care units are at higher risk for development of pressure ulcersthan other patients. $n order to prevent pressure ulcers from developing in intensive care patients,

risk for development of pressure ulcers must be assessed accurately.

Objectives To evaluate the predictive validity of the "raden scale for assessing risk for

development of pressure ulcers in intensive care patients by using 7 years of data from electronic

health records.

!ethods 2ata from the electronic health records of patients admitted to intensive care units between Manuary 6, )**<, and 2ecember 56, )*6*, were extracted from the data warehouse of an

academic medical center. Eredictive validity was measured by using sensitivity, specificity,

positive predictive value, and negative predictive value. The receiver operating characteristiccurve was generated, and the area under the curve was reported.

Results ! total of <<4* intensive care patients were included in the analysis. ! cutoff score of 69

on the "raden scale had a sensitivity of *.487, specificity of *.)*<, positive predictive value of

*.667, and negative predictive value of *.4<<. The area under the curve was *.9<) (48= C$,*.995;*.915%. The optimal cutoff for intensive care patients, determined from the receiver

operating characteristic curve, was 65.

Conclusions The "raden scale shows insufficient predictive validity and poor accuracy in

discriminating intensive care patients at risk of pressure ulcers developing. The "raden scale

may not sufficiently reflect characteristics of intensive care patients. Kurther research is neededto determine which possibly predictive factors are specific to intensive care units in order to

increase the usefulness of the "raden scale for predicting pressure ulcers in intensive care patients.

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