Kordasiewicz L, Fik K, Petry C
… +1 more, Sturtz J
Crit Care Nurse
· 2025 Aug · PMID 40748930
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INTRODUCTION: Limited research on preventing and managing skin failure events such as deep tissue injuries and Kennedy terminal ulcers is available. These skin failure events often appear among patients experiencing mult...INTRODUCTION: Limited research on preventing and managing skin failure events such as deep tissue injuries and Kennedy terminal ulcers is available. These skin failure events often appear among patients experiencing multiple organ failure with hypoperfusion to the skin despite evidence-based nursing interventions to enhance skin integrity. CLINICAL FINDINGS: A 68-year-old White man presented at a trauma hospital after several recent falls at home. He immediately required hospitalization. Several medical complications, including a deep tissue pressure injury, evolved. The pressure injury remained clinically stable throughout his hospitalization. DIAGNOSIS: The patient received a diagnosis of deep tissue pressure injury. INTERVENTIONS: Aggressive medical management, implementation of a turning schedule on a low-air-loss surface, foam dressings, and offloading boots were used to prevent skin damage and preserve skin integrity. OUTCOMES: The patient's condition declined and he developed a deep tissue pressure injury on the sacrum that did not advance or become infected. The family agreed to comfort measures and he soon died. CONCLUSION: Skin failure events such as deep tissue pressure injuries and Kennedy terminal ulcers often occur among critically ill patients, older patients, those approaching end of life, and other patients with prolonged pressure upon body surfaces. The Centers for Medicare & Medicaid Services holds hospitals financially accountable for sequelae of events associated with hospital-acquired full-thickness pressure injuries. Additional research to categorize skin failure events as secondary to hypoperfusion and not medical mismanagement can optimize patient safety and positively impact the finances and credibility of medical organizations.
Newman A, Lasseigne J, Goldhirsch S
… +5 more, Chai E, Acquah S, Davis C, Stanley K, Mehta A
Crit Care Nurse
· 2025 Aug · PMID 40748924
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INTRODUCTION: Given the serious illness burden of patients in medical intensive care units, palliative care is a key element of their care. This case discussion highlights the role of the palliative care specialty regist...INTRODUCTION: Given the serious illness burden of patients in medical intensive care units, palliative care is a key element of their care. This case discussion highlights the role of the palliative care specialty registered nurse in an embedded palliative care model in medical intensive care units. CLINICAL FINDINGS: A 44-year-old female patient with decompensated cirrhosis was transferred to the study hospital for liver transplant evaluation. Her hospital stay involved multiple complications. DIAGNOSIS: The patient was determined to have palliative care needs. Multiple areas of intervention were identified. INTERVENTIONS: A model including a palliative care specialty registered nurse was initiated in the medical intensive care unit. OUTCOMES: The palliative care specialty registered nurse had 2 roles: (1) optimizing patient care by partnering with medical intensive care unit colleagues to develop a plan of care aligned with patient and family values and preferences and (2) supporting and enhancing critical care nursing excellence by helping bedside nurses advocate for the patient's palliative care needs. Nurses were also empowered with communication skills to engage with patients, family members, and primary team colleagues. CONCLUSION: The palliative care specialty registered nurse model can be used in various intensive care unit settings. However, the complex care needs of critically ill patients, the unique nature and structural variations across critical care settings, and the resources required to implement this model are potential challenges.
Crit Care Nurse
· 2025 Aug · PMID 40748923
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BACKGROUND: Early identification and treatment of clinical deterioration is crucial for improving outcomes among hospital patients. A high-acuity response team (HART) program can integrate early warning systems and proac...BACKGROUND: Early identification and treatment of clinical deterioration is crucial for improving outcomes among hospital patients. A high-acuity response team (HART) program can integrate early warning systems and proactive rounding by critical care nurses to prevent unplanned escalations in care. LOCAL PROBLEM: During the COVID-19 pandemic, a HART program was inconsistently implemented because of intensive care unit staffing shortages. Barriers to optimizing the HART nurse role included inconsistent practices, lack of clear role expectations, and frequent reassignment of HART nurses to compensate for staffing shortages. METHODS: Postpilot implementation of the HART program began in October 2019. Critical care nurses were designated as HART nurses, responsible for monitoring the Rothman Index, and assisted bedside nurses with high-acuity patients. Data were collected from 2019 to 2023 and were analyzed using IBM SPSS Statistics, version 29, with statistical significance defined as P ≤ .05. RESULTS: The HART program significantly reduced 24-hour intensive care unit readmissions by 33.9% and 72-hour readmissions by 32.7%. HART nurse consultations increased by 35.7%. There were clinically significant decreases in code blue emergencies outside the intensive care unit (22.2%) and overall (16.7%), although no statistically significant differences were found for rapid response team activations or unplanned intensive care unit transfers. CONCLUSION: The HART nurse program effectively integrates early warning systems and rapid response teams, significantly reducing intensive care unit readmissions and improving patient care. Clear role expectations and dedicated staffing are needed, and continuous stakeholder engagement and resource allocation are essential for sustaining the program's success.
Mazzeffi M, White MP, Wade A
… +10 more, Jordan J, Zaaqoq A, Schneiderman E, Phillips T, Davis C, Dahl J, McNeil J, Singh K, Buckner J, Sifri CD
Crit Care Nurse
· 2025 Jun · PMID 40449934
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BACKGROUND: Central line [catheter]-associated bloodstream infection (CLABSI) is associated with longer stays and increased cost, morbidity, and mortality. LOCAL PROBLEM: An academic cardiothoracic intensive care unit ha...BACKGROUND: Central line [catheter]-associated bloodstream infection (CLABSI) is associated with longer stays and increased cost, morbidity, and mortality. LOCAL PROBLEM: An academic cardiothoracic intensive care unit had a high CLABSI incidence (standardized infection ratio of 2.3 at baseline). The hospital's executive leadership team (chief nursing officer, chief medical officer, and chief of quality and performance improvement) directed intensive care unit leaders to reduce the standardized infection ratio. METHODS: Interprofessional CLABSI reduction efforts were formulated using A3 methods based on the plan-do-check-act cycle. Unit leaders (nurses, physicians, advanced practice providers, and allied health professionals) met every 2 weeks for 2 years to formulate CLABSI reduction efforts. Efficacy of CLABSI reduction was evaluated with the standardized infection ratio. INTERVENTIONS: Quality improvement activities included improved hand hygiene compliance, optimization of central venous catheter insertion, improved chlorhexidine dressing adherence, daily assessment of high-risk catheters for removal, use of an electronic intensive care unit bundle checklist to highlight central venous catheter duration for clinicians, and promotion of a blood culturing stewardship program with guidance on when to obtain blood samples for culture. RESULTS: Interprofessional CLABSI reduction efforts reduced the standardized infection ratio from 2.3 to 0.8 over 3 years. The standardized utilization ratio, reflecting observed to expected central venous catheter days, decreased from 1.0 to 0.89. CONCLUSION: Interprofessional CLABSI reduction efforts can be effective in a cardiac surgical intensive care unit and improve patient safety. Keys to success include teamwork, accountability, acceptance from intensive care unit staff, and support from hospital executive leaders.
Crit Care Nurse
· 2025 Jun · PMID 40449933
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BACKGROUND: Surrogate decision-makers frequently experience negative emotional and physical outcomes due to their decision-making role in the adult intensive care unit. These negative outcomes may be mitigated by high-qu...BACKGROUND: Surrogate decision-makers frequently experience negative emotional and physical outcomes due to their decision-making role in the adult intensive care unit. These negative outcomes may be mitigated by high-quality communication, but for this type of communication to occur, surrogate decision-makers must have trust in health care professionals. OBJECTIVE: To explore what is known about surrogate decision-makers' trust in health care professionals in the adult intensive care unit setting. METHODS: In this scoping review, CINAHL, APA PsycArticles, APA PsycInfo, MEDLINE, the Cochrane Library, the Web of Science, and Google Scholar were searched from inception to March 9, 2024. RESULTS: A total of 64 articles met the inclusion criteria. Surrogate decision-makers step into their decision-making role with a baseline level of trust in health care professionals, which is then modified by those professionals' behaviors such as technical competence, communication, honesty, benevolence, and interpersonal skills. The surrogate decision-maker's level of trust in health care professionals affects the surrogate's decision-making and behavior in the intensive care unit. A high-quality instrument is needed to measure surrogate decision-maker trust in health care professionals in the adult intensive care unit setting so that future research can focus on validating various trust-building interventions in this population. CONCLUSION: Bedside staff members should incorporate the currently available research findings about building trust with surrogate decision-makers into their professional practice. Future research should focus on the development, validation, and dissemination of a new instrument designed specifically to measure surrogate decision-maker trust in health care professionals.
Cao W, Chang H, Li M
… +4 more, Fan L, Tian F, Liu G, Zhang Y
Crit Care Nurse
· 2025 Jun · PMID 40449932
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BACKGROUND: Early postpyloric feeding provides effective and safe enteral nutrition for patients with large hemispheric infarction receiving therapeutic hypothermia. LOCAL PROBLEM: Patients with large hemispheric infarct...BACKGROUND: Early postpyloric feeding provides effective and safe enteral nutrition for patients with large hemispheric infarction receiving therapeutic hypothermia. LOCAL PROBLEM: Patients with large hemispheric infarction undergoing therapeutic hypothermia often have gastrointestinal dysfunction and undergo repeated bedside attempts at blind postpyloric feeding tube placement. Confirming tube position via radiography can delay nutrient intake, increase costs, and expose patients to unnecessary radiation. METHODS: In this quality improvement study, specialist nurses were trained to use ultrasonography instead of radiography to confirm postpyloric feeding tube position, reducing reliance on ancillary services. Preimplementation and postimplementation data included time from tube placement to first feeding and the frequency of radiography use. Surveys were conducted to assess the health care team's satisfaction with the new process. RESULTS: Sixty-seven placements (30 before implementation, 37 after implementation) were evaluated. Feeding start times significantly decreased by 34.85% (mean [SD], 741.20 [192.73] minutes before implementation vs 482.86 [166.15] minutes after implementation; P < .001). The addition of ultrasound guidance for postpyloric feeding tube placement significantly decreased the number of abdominal radiographs per patient by 56.0% (mean [SD], 2.5 [0.9] before implementation vs 1.1 [0.4] after implementation; P < .001). Most health care team members indicated that this practice change reduced the time to initiation of enteral nutrition for patients with large hemispheric infarction receiving therapeutic hypothermia. CONCLUSIONS: By improving processes, we reduced feeding start times, minimized radiography use, and enhanced the health care team's satisfaction with postpyloric feeding tube placement for patients receiving therapeutic hypothermia.
Sabolish RM, Caldwell HK, Pennartz LE
… +2 more, Bailey KE, Xavier LR
Crit Care Nurse
· 2025 Jun · PMID 40449931
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BACKGROUND: After terminal extubation, more than 30% of patients experience a period of persistent dyspnea. Practices regarding terminal extubation at the end of life vary widely, and evidence for practice superiority is...BACKGROUND: After terminal extubation, more than 30% of patients experience a period of persistent dyspnea. Practices regarding terminal extubation at the end of life vary widely, and evidence for practice superiority is lacking. Critical care nurses are often tasked with making intervention decisions. LOCAL PROBLEM: At a 368-bed acute care hospital, nurses reported a lack of training on managing end-of-life symptoms associated with terminal extubation and the need for a standardized protocol to guide assessment and interventions. The aim of this study was to examine how use of an evidence-based terminal extubation protocol affects bedside nursing practice and clinician experience. METHODS: An interprofessional work group conducted a needs assessment, developed a terminal extubation protocol, provided education, and implemented the protocol. The protocol included the use of the Respiratory Distress Observation Scale as a new tool to evaluate patient distress and specified reassessment frequency, anticipated dose calculation, titration parameters, and steps for weaning. The work group examined the use of continuous infusion, bolus dosing, titration, and interventions before and after protocol implementation. RESULTS: Findings after protocol implementation included an increased reliance on bolus dosing and titration for evolving symptoms, greater use of evidence-based end-of-life medications, improved documentation demonstrating calculation of anticipatory doses, and an average time from start of process to extubation of approximately 21 minutes. Clinicians reported that use of the protocol improved symptom management. CONCLUSION: A terminal extubation protocol can provide critical care nurses with an objective tool to guide assessment and interventions. Effective protocol implementation requires strong interprofessional collaboration.
Crit Care Nurse
· 2025 Jun · PMID 40449930
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BACKGROUND: Women with large breasts are at risk for wounds after sternotomy. LOCAL PROBLEM: Over 12 months, 7 of 110 female patients who underwent sternotomy (6.4%) had 274 additional hospital days related to pressure i...BACKGROUND: Women with large breasts are at risk for wounds after sternotomy. LOCAL PROBLEM: Over 12 months, 7 of 110 female patients who underwent sternotomy (6.4%) had 274 additional hospital days related to pressure injuries and sternal dehiscence after sternotomy. The financial burden for the longer stays was more than $751 000. The purpose of this quality improvement initiative was to implement a soft, comfortable bra to prevent wounds and sternal dehiscence in female patients after sternotomy. METHODS: Nurses implemented a new bra that reduced wound tension, had stretchable material that could expand for swelling, did not absorb moisture, and was available in a range of sizes to accommodate all women. Staff members measured patients' chest circumference before surgery and dressed patients in the bra in the operating room immediately after surgery. Patients wore the bra for breast support 20 to 24 hours a day for 6 weeks after surgery. RESULTS: The new bra was used for 82 patients. No patients who wore the bra developed sternal dehiscence or chest pressure wounds. The wound incidence rate decreased from 6.4% to 0%. CONCLUSION: Female patients undergoing sternotomy should be dressed in a comfortable and appropriately sized bra immediately after surgery and should wear it for 6 weeks. Such a bra can help prevent sternal dehiscence and pressure injuries.
Crit Care Nurse
· 2025 Jun · PMID 40449927
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BACKGROUND: Patients with critical illness often seek meaningful relationships with members of their care teams. The patient experience can be enhanced through a goals-of-care conversation, an aspect of palliative care t...BACKGROUND: Patients with critical illness often seek meaningful relationships with members of their care teams. The patient experience can be enhanced through a goals-of-care conversation, an aspect of palliative care that focuses on the patient-clinician relationship. Despite recommendations for early palliative care interventions, no standardized time for generalists to initiate palliative care interventions in the acute care setting has been established. LOCAL PROBLEM: An academic hospital identified a need for earlier palliative care interventions for patients admitted to the medical intensive care unit. The aim of this quality improvement project was to improve early palliative care interventions in the intensive care unit by increasing numbers of documented surrogate decision-makers and goals-of-care conversations. Newman's theory of health as expanding consciousness was used as a guide to improve the patient-clinician relationship through communication, early establishment of goals of care, and development of patient-centered care. METHODS: Recently admitted patients were screened during interprofessional team huddles with a modified surprise question ("Would you be surprised if this patient died during this hospitalization?") to identify those who might benefit from an early goals-of-care conversation. The preimplementation group included all admitted patients and the postimplementation group included only patients with a "no" on the surprise question. RESULTS: Analysis included 174 patients (139 before implementation, 35 after implementation). In the preimplementation group, 99 patients (71%) had documented surrogate decision-makers and 26 (19%) had documented goals-of-care conversations. In the postimplementation group, 34 patients (97%) had documented surrogate decision-makers and 14 (40%) had documented goals-of-care conversations. CONCLUSION: Patients screened with the modified surprise question upon admission to the intensive care unit received earlier palliative care interventions, enhancing patient-centered care.
BACKGROUND: Hospitalized patients often experience sleep disruption that fragments their sleep and disturbs their circadian rhythms, putting them at risk for sleep deprivation. The risk increases with greater severity of...BACKGROUND: Hospitalized patients often experience sleep disruption that fragments their sleep and disturbs their circadian rhythms, putting them at risk for sleep deprivation. The risk increases with greater severity of illness and is especially high in intensive care unit patients. Sleep deprivation can prolong the intensive care unit stay, contribute to emotional and physiological distress, and even increase the patient's risk of death. LOCAL PROBLEM: Critical care nurses in a 28-bed medical intensive care unit reported that patients often complained of sleep disruption or exhibited emotional and physical distress resulting from sleep deprivation. An analysis of the gap between recommended evidence-based best practice and current practices in the unit revealed numerous opportunities to improve patients' sleep. The aim of this evidence-based quality improvement project was to increase interprofessional adherence to an existing sleep-promoting schedule to reduce avoidable interruptions and improve patient sleep quality. METHODS: To promote sleep, staff member interactions with patients between midnight and 4 am were minimized, if appropriate. Documented patient encounters and call bell initiation were evaluated as process measures. Patients' self-perceived sleep quality, an outcome measure, was evaluated using the Richards-Campbell Sleep Questionnaire. RESULTS: Adherence to a sleep-promoting schedule reduced patient sleep interruptions between midnight and 4 am by as much as two-thirds while increasing patients' overall self-perceived sleep quality by 6.7 percentage points. CONCLUSION: An interprofessional effort to minimize patient interruptions at night in an intensive care unit setting led to improved patient sleep quality and sustainable practice changes.