Crit Care Nurse
· 2024 Oct · PMID 39348921
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Advances in fire safety and building construction have made fires in modern health care facilities uncommon and easily contained. Therefore, emergent hospital evacuations resulting from an internal fire are rare. On Janu...Advances in fire safety and building construction have made fires in modern health care facilities uncommon and easily contained. Therefore, emergent hospital evacuations resulting from an internal fire are rare. On January 4, 2017, a fire occurred at the John Sealy Hospital, part of the University of Texas Medical Branch at Galveston, resulting in emergent evacuation of the hospital building and an adjacent office and patient care building. The internal emergency response system was quickly activated, and more than 100 patients and 200 staff members were evacuated within 27 minutes with no fire- or smoke-related injuries. Obstacles encountered during the evacuation process included difficulties with communication and confirming patient count in a timely manner. This article describes the emergent hospital evacuation during the fire, summarizes the subsequent reflections of a multiagency after-action review, and issues a call to action for further research and publication on emergency patient evacuation.
Guest M, Craven K, Tellson AM
… +4 more, Porter M, James N, Turley L, Smitherman J
Crit Care Nurse
· 2024 Aug · PMID 39084672
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BACKGROUND: The Society of Critical Care Medicine has established guidelines to manage pain, sedation, delirium, immobility, family participation, and sleep disruption in the intensive care unit, a set of interventions k...BACKGROUND: The Society of Critical Care Medicine has established guidelines to manage pain, sedation, delirium, immobility, family participation, and sleep disruption in the intensive care unit, a set of interventions known as the intensive care unit liberation (ABCDEF) bundle. Adherence to these guidelines has shown positive results. LOCAL PROBLEM: In the intensive care units of a level I trauma academic teaching hospital in central Texas, the rate of bedside nursing staff adherence to the ABCDEF bundle was only 67.1% in January 2022. The aim of this quality improvement project was to improve adherence to the bundle. METHODS: Knowledge gaps were found to be the driver of the low adherence rate. Two primary needs were identified: (1) education on the elements of the ABCDEF bundle and (2) increased awareness and recognition of incomplete and incorrect documentation. Interventions included focused education on intensive care unit liberation. RESULTS: From February to June 2022, overall adherence to the ABCDEF bundle increased from 67.1% to 95.3%, ventilator use decreased by approximately 10%, and restraint use dropped by about 9%. The incidence of delirium increased, but this increase was due to incorrect patient assessment before the interventions. CONCLUSION: The results of this project are consistent with literature demonstrating that a multifaceted approach to improving ABCDEF bundle adherence can produce sustainable improvement in patient outcomes. This report may help other organizations facing similar challenges improve adherence to the bundle in a postpandemic environment.
Crit Care Nurse
· 2024 Aug · PMID 39084671
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INTRODUCTION: Hepatic portal venous gas is an extremely rare symptom of gas accumulation in the portal venous system. This disease has an acute onset, a rapid progression, and an extremely high mortality rate. This repor...INTRODUCTION: Hepatic portal venous gas is an extremely rare symptom of gas accumulation in the portal venous system. This disease has an acute onset, a rapid progression, and an extremely high mortality rate. This report describes a patient with mesenteric and hepatic portal venous gas caused by intestinal microbiota disturbance-induced gut-derived infection after ileostomy. The patient recovered and was discharged after conservative treatment. Nursing management of patients with mesenteric and hepatic portal venous gas is discussed. CLINICAL FINDINGS: A 76-year-old patient developed septic shock, paralytic intestinal obstruction, and mesenteric and hepatic portal venous gas after undergoing ileostomy. DIAGNOSIS: Mesenteric and hepatic portal venous gas was diagnosed on the basis of abdominal contrast-enhanced computed tomography findings. INTERVENTIONS: The treatment plan included early control of infection, early identification and nursing care of gut-derived infection caused by intestinal microbiota disturbance, early identification of paralytic intestinal obstruction, relief of intestinal obstruction and prevention of intestinal ischemia, and early nutritional support. OUTCOMES: On day 18 of hospitalization, the patient was transferred to the general ward and resumed eating, producing gas, and defecating. His abdominal signs and infection indicator levels were normal. On day 27, the patient was discharged home. CONCLUSION: This case provides an in-depth understanding of the care of patients with mesenteric and hepatic portal venous gas and emphasizes the important role of bedside nurses in evaluating and treating these patients. This report may help nurses care for similar patients.
Crit Care Nurse
· 2024 Aug · PMID 39084670
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BACKGROUND: Patients in intensive care units are exposed to many factors that can negatively affect the quality of their sleep. OBJECTIVE: To describe the latest findings regarding sleep quality improvement in intensive...BACKGROUND: Patients in intensive care units are exposed to many factors that can negatively affect the quality of their sleep. OBJECTIVE: To describe the latest findings regarding sleep quality improvement in intensive care unit patients. METHODS: An integrative literature review was conducted in the CINAHL, PubMed, Cochrane Library, and MEDLINE databases in April and May 2023. The following keywords were used: intensive care units, promotion, sleep quality, and sleep. The Critical Appraisal Skills Programme tool was used to assess the quality of individual studies. RESULTS: Of 159 articles identified, 10 were included in the final analysis. The findings were grouped into 4 thematic categories: consequences of poor sleep quality, factors affecting sleep quality, pharmacologic ways to improve sleep quality, and nonpharmacologic ways to improve sleep quality. DISCUSSION: Various pharmacologic and nonpharmacologic treatments are used in clinical settings. Nonpharmacologic interventions include sleep masks, earplugs, reductions in alarm volume, and reductions in nighttime interventions. Relaxation techniques include aromatherapy, music therapy, and acupressure. CONCLUSIONS: The most effective way to improve sleep for intensive care unit patients is to use a combination of pharmacologic and nonpharmacologic interventions. Among the latter, the use of earplugs and sleep masks is simplest.
Crit Care Nurse
· 2024 Aug · PMID 39084669
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BACKGROUND: Despite implementation of central catheter bundles, central line [catheter]-associated bloodstream infections (CLABSIs) remain a preventable hospital-acquired infection. LOCAL PROBLEM: A new population of pat...BACKGROUND: Despite implementation of central catheter bundles, central line [catheter]-associated bloodstream infections (CLABSIs) remain a preventable hospital-acquired infection. LOCAL PROBLEM: A new population of patients with pulmonary artery catheters was introduced to the cardiac progressive care unit, increasing central catheter days, device use, and CLABSI rate. METHODS: A quality improvement project was conducted. Nursing staff implemented a standardized central catheter rounding process 3 days a week to critically assess all central catheter dressings, deter-mine the necessity of each central catheter, and educate patients on the importance of keeping central catheter dressings clean, dry, and intact. Data were collected during central catheter rounds for each patient, entered in an electronic survey tool via mobile devices, and analyzed. RESULTS: From July 2019 through June 2022, a total of 2692 rounds were conducted for 707 individual patients with 3064 central catheters. Main interventions were dressing management, monitoring insertion site bleeding that extended beyond edges of the chlorhexidine gluconate pad, treating patients' allergies to products, and maintaining sustainability within the unit. Central catheter rounds decreased the CLABSI rate from 1.86 to 0.0 despite the continued increase in central catheter days. CONCLUSIONS: Central catheter dressing assessment, intervention, and education help reduce CLABSIs. Central catheter rounds are an important adjunct to the CLABSI bundle. A central catheter dressing management algorithm helps nurses decide when to change a dressing and which type of dressing to use.
Crit Care Nurse
· 2024 Aug · PMID 39084668
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BACKGROUND: High-quality sleep is important for optimal patient recovery. Sleep deprivation during hospitalization may lead to poor patient outcomes. OBJECTIVE: To examine whether implementation of a sleep promotion bund...BACKGROUND: High-quality sleep is important for optimal patient recovery. Sleep deprivation during hospitalization may lead to poor patient outcomes. OBJECTIVE: To examine whether implementation of a sleep promotion bundle in the intensive care unit affects rates of delirium and agitation, restraint use, and length of stay. METHODS: An evidence-based sleep promotion bundle was developed and implemented in 2 intensive care units in a 1025-bed level I trauma teaching hospital. Deidentified data from the electronic health record were obtained for patients hospitalized before and during the intervention. Data included scores on the Confusion Assessment Method for the Intensive Care Unit, Richmond Agitation-Sedation Scale, and Glasgow Coma Scale; restraint use; and hospital and intensive care unit length of stay. RESULTS: A total of 137 patients during the preintervention period and 149 patients during the intervention period were hospitalized in the intensive care units and met inclusion criteria. A 9-percentage-point decrease in the incidence of delirium from before to during the intervention was found, although it was not statistically significant (P = .07). Significant reductions were found in both intensive care unit (P = .04) and hospital (P = .03) length of stay. A significant decrease was found in Richmond Agitation-Sedation Scale high scores for patients requiring mechanical ventilation (P = .03). No significant differences were found in Richmond Agitation-Sedation Scale low scores, Glasgow Coma Scale scores, or restraint use. CONCLUSIONS: Critical care nurses are in an optimal position to implement evidence-based sleep promotion measures. Further research on sleep promotion bundles is needed.
Crit Care Nurse
· 2024 Aug · PMID 39084667
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INTRODUCTION: This is the first report of a patient who developed cardiogenic shock after receiving oral chemotherapy with capecitabine and was treated with venoarterial extracorporeal membrane oxygenation combined with...INTRODUCTION: This is the first report of a patient who developed cardiogenic shock after receiving oral chemotherapy with capecitabine and was treated with venoarterial extracorporeal membrane oxygenation combined with continuous renal replacement therapy. CLINICAL FINDINGS: A 58-year-old man developed an arrhythmia that rapidly progressed to cardiogenic shock and cardiac arrest after receiving oral capecitabine tablets to treat a rectal malignancy. INTERVENTIONS: The patient was treated with venoarterial extracorporeal membrane oxygenation in combination with continuous renal replacement therapy. OUTCOME: The patient made a full recovery and was discharged from the hospital. CONCLUSION: The use of comprehensive supportive treatments such as extracorporeal membrane oxygenation combined with continuous renal replacement therapy in patients with capecitabine-induced cardiac arrest can rapidly reduce drug concentrations, eliminate harmful substances, and improve the prognosis.
Simmons JSC, Bourgault AM, Sole ML
… +1 more, Peach BC
Crit Care Nurse
· 2024 Jun · PMID 38821530
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BACKGROUND: Chlorhexidine gluconate has been considered the criterion standard of oral care for patients receiving mechanical ventilation because of its ability to reduce the incidence of ventilator-associated events. Op...BACKGROUND: Chlorhexidine gluconate has been considered the criterion standard of oral care for patients receiving mechanical ventilation because of its ability to reduce the incidence of ventilator-associated events. Optimal concentrations and frequencies remain unclear, as do adverse events related to mortality in various intensive care unit populations. OBJECTIVE: To examine the current evidence for the efficacy of chlorhexidine gluconate in reducing the incidence of ventilator-associated events, mortality, intensive care unit length of stay, and duration of mechanical ventilation in patients receiving ventilator support. METHODS: In this integrative review, CINAHL (Cumulative Index to Nursing and Allied Health Literature), MEDLINE, and Health Source: Nursing/Academic Edition were searched using terms related to mechanical ventilation and chlorhexidine gluconate oral care with dates ranging from 2012 to 2023. RESULTS: Seventeen articles were included in this review: 8 systematic reviews, 8 randomized clinical trials (3 of which were not included in any systematic review), and 1 quasi-experimental study. Chlorhexidine gluconate oral care was associated with a reduced incidence of ventilator-associated events, but efficacy depended on concentration and frequency of administration. With stratification by intensive care unit population type, a nonsignificant trend toward increased mortality was found among non-cardiac surgical patients who received this care. CONCLUSION: The evidence regarding the efficacy of chlorhexidine gluconate oral care in reducing ventilator-associated events in specific intensive care unit populations is contradictory. Recently published guidelines recommend de-implementation of chlorhexidine gluconate oral care in all patients receiving mechanical ventilation. Such care may be beneficial only in the cardiac surgical population.
Chilson S, Charais C, Jones J
… +1 more, Goforth C
Crit Care Nurse
· 2024 Jun · PMID 38821529
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BACKGROUND: The COVID-19 pandemic resulted in unprecedented health care challenges and transformation of nursing practice. A significant challenge faced by health care systems was the rapid identification and training of...BACKGROUND: The COVID-19 pandemic resulted in unprecedented health care challenges and transformation of nursing practice. A significant challenge faced by health care systems was the rapid identification and training of nurses in various specialties, including critical care, to care for a large influx of critically ill patients. OBJECTIVE: To identify common themes and modalities that support best practices for the rapid training of registered nurses in team-based critical care nursing. METHODS: With the Whittemore and Knafl integrative review methodology as a framework, a literature review was conducted using a priori search terms. RESULTS: The integrative review included 11 articles and revealed 3 common themes: communication challenges, team dynamics, and the methodological approach to implementing training. DISCUSSION: This integrative review highlighted 3 main implications for future practice and policy in the event of another pandemic. Clear and frequent communication, multidisciplinary huddles, and open communication are paramount for mitigating role confusion and enhancing team dynamics. A multimodal approach to training appears to be feasible and effective for rapidly training support registered nurses to care for critically ill patients. However, the optimal training duration remains unidentified. CONCLUSIONS: Rapidly training registered nurses to care for critically ill patients in a team-based dynamic is a safe and effective course of action to mitigate staff shortages if another pandemic occurs.
Rittenhouse A, Ostendorf M, Johns C
… +1 more, Gerdisch M
Crit Care Nurse
· 2024 Jun · PMID 38821528
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BACKGROUND: Patients with anemia have poorer outcomes following cardiac surgery than do those without anemia. To improve outcomes, the Enhanced Recovery After Surgery cardiac recommendations include optimizing patients'...BACKGROUND: Patients with anemia have poorer outcomes following cardiac surgery than do those without anemia. To improve outcomes, the Enhanced Recovery After Surgery cardiac recommendations include optimizing patients' condition, including treating anemia, before surgery. LOCAL PROBLEM: Despite implementing Enhanced Recovery After Surgery initiatives, a midwestern cardiothoracic surgery group recognized a care gap in preoperative patients with anemia. No standardized protocol was in use. METHODS: An anemia optimization protocol was developed for perioperative care of patients with anemia. Data from retrospective medical record review were analyzed to determine relationships between protocol use and secondary outcomes. The protocol was created using best evidence and expert consensus. Cardiac surgery and hematology specialists revised the protocol and agreed on a final version. The protocol was integrated into the consultation process for cardiac surgery patients. RESULTS: During the implementation period, 23 of 55 patients with anemia (42%) received interventions via the anemia optimization protocol. The mean quantity of packed red blood cells transfused perioperatively per patient was 1.9 U in the protocol group and 3.5 U in the nonprotocol group. In the subgroup of patients experiencing postoperative acute kidney injury, the mean increase in creatinine level was 0.65 mg/dL in the protocol group and 1.52 mg/dL in the nonprotocol group. Four patients in the protocol group (17%) and 6 patients in the nonprotocol group (19%) experienced postoperative acute kidney injury. CONCLUSION: Preoperative anemia is associated with poorer cardiac surgical outcomes. Incorporating the anemia optimization protocol into practice may mitigate the risk of postoperative complications for patients with anemia. Continued use of the protocol is recommended.
Crit Care Nurse
· 2024 Jun · PMID 38821527
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BACKGROUND: Iatrogenic malnutrition is a significant burden to patients, clinicians, and health care systems. Compared with well-nourished patients, underfed patients (those who receive less than 80% of their daily energ...BACKGROUND: Iatrogenic malnutrition is a significant burden to patients, clinicians, and health care systems. Compared with well-nourished patients, underfed patients (those who receive less than 80% of their daily energy requirement) have more adverse outcomes related to nutritional status. Volume-based protocols allow for catch-up titrations, are consistently superior to rate-based protocols, and can be implemented in most settings. LOCAL PROBLEM: This project was conducted in an 8-bed neuroscience intensive care unit in which up to 41% of patients who required enteral feeding were underfed. METHODS: This quality improvement clinical practice change project used a before-and-after design to evaluate (1) the effect of implementing a volume-based feeding protocol on the delivery of enteral feeds and (2) the effect of a nutrition-based project on staff members' attitudes regarding nutrition in critical care. The effectiveness of a volume-based feeding titration protocol was compared with that of a rate-based feeding protocol for achieving delivery of at least 80% of prescribed nutrition per 24-hour period. Staff members' attitudes were assessed using a survey before and after the project. RESULTS: During 241 enteral feeding days (n = 40 patients), the percentage of delivered enteral feeding volume and the percentage of days patients received at least 80% of the prescribed volume increased after volume-based feeding was implemented. After project implementation, 74 staff members reported increased emphasis on nutrition delivery in their practice and a higher level of agreement that nutrition is a priority when caring for critically ill patients. CONCLUSIONS: Using a volume-based feeding protocol with supplemental staff education resulted in improved delivery of prescribed enteral feeding.
Tsiouris A, Protos AN, Keys VD
… +3 more, Chambers D, Jeyakumar AKC, Shake JG
Crit Care Nurse
· 2024 Jun · PMID 38821526
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BACKGROUND: Emergency resternotomy in the intensive care unit for a patient who has undergone cardiac surgery can be daunting for surgeons and critical care staff. Clinicians involved are often unfamiliar with the surgic...BACKGROUND: Emergency resternotomy in the intensive care unit for a patient who has undergone cardiac surgery can be daunting for surgeons and critical care staff. Clinicians involved are often unfamiliar with the surgical instruments and techniques needed. LOCAL PROBLEM: After an emergency intensive care unit resternotomy resulted in suboptimal performance and outcome, protocols for emergency resternotomy were established and improved. METHODS: Education and simulation training were used to improve staff comfort and familiarity with the needed techniques and supplies. The training intervention included simulations to provide hands-on experience, improve staff familiarity with resternotomy trays, and streamline emergency sternotomy protocols. Preintervention and postintervention surveys were used to assess participants' familiarity with the implemented plans and algorithms. RESULTS: All 44 participants (100%) completed the preintervention survey, and 41 of 44 participants (93%) returned the postintervention survey. After the intervention, 95% of respondents agreed that they were prepared to be members of the team for an emergency intensive care unit sternotomy, compared with 52% of respondents before the intervention. After the intervention, 95% of respondents strongly agreed or agreed that they could identify patients who might need emergency sternotomy, compared with 50% before the intervention. The results also showed improvement in staff members' understanding of team roles, activation and use of the emergency sternotomy protocol, and differences between guidelines for resuscitating patients who experience cardiac arrest after cardiac surgery and the post-cardiac arrest Advanced Cardiovascular Life Support protocol. CONCLUSION: Results of this quality improvement project suggest that simulation training improves staff comfort with and understanding of emergency resternotomy.
Hadley S, Thompson J, Beltramo F
… +2 more, Marcum J, Reuter-Rice K
Crit Care Nurse
· 2024 Jun · PMID 38821525
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BACKGROUND: The mortality rate of pediatric patients who require continuous renal replacement therapy is approximately 42%, and outcomes vary considerably depending on underlying disease, illness severity, and time of di...BACKGROUND: The mortality rate of pediatric patients who require continuous renal replacement therapy is approximately 42%, and outcomes vary considerably depending on underlying disease, illness severity, and time of dialysis initiation. Delay in the initiation of such therapy may increase mortality risk, prolong intensive care unit stay, and worsen clinical outcomes. LOCAL PROBLEM: In the pediatric intensive care unit of an urban level I trauma children's hospital, continuous renal replacement therapy initiation times and factors associated with delays in therapy were unknown. METHODS: This quality improvement process involved a retrospective review of data on patients who received continuous dialysis in the pediatric intensive care unit from January 1, 2017, to December 31, 2021. The objectives were to examine the characteristics of the children requiring continuous renal replacement therapy, therapy initiation times, and factors associated with initiation delays that might affect unit length of stay and mortality. RESULTS: During the study period, 175 patients received continuous renal replacement therapy, with an average initiation time of 11.9 hours. Statistically significant associations were found between the degree of fluid overload and mortality (P < .001) and between the presence of acute kidney injury and prolonged length of stay (P = .04). No significant association was found between therapy initiation time and unit length of stay or mortality, although the average initiation time of survivors was 5.9 hours shorter than that of nonsurvivors. CONCLUSION: Future studies are needed to assess real time delays and to evaluate if the implementation of a standardized initiation process decreases initiation time.