The effects of nursing staff inexperience (NSI) on the occurrence of adverse patient experiences in ICUs

Epidemiology of adverse events in Intensive Medicine units

The severity of the critically ill patient, the practice of diagnostic procedures and invasive treatments, the high number of drugs administered, a high volume of data generated during the care of the critically ill patient along with a technical work environment, the stress and workload of work of professionals, are circumstances that favor the appearance of errors, turning Intensive Medicine Services into risk areas for adverse events to occur. Knowing their epidemiology is the first step to improve the safety of the care we provide to our patients, because it allows us to identify risk areas, analyze them and develop strategies to prevent the adverse events, or if this is not possible, be able to manage them. This article analyzes the main studies published to date on incidents related to safety in the field of critically ill patients.

Efficacy of a theoretical and practical programme to newly hired nursing personnel in a Paediatric Intensive Care Unit: A pilot study

AIMS

(1) to design a training programme for newly hired nursing personnel and (2) to determine self-perception and perceived stress before and after the theoretical and practical parts of the programme with high fidelity simulation activities.

METHODS

A pilot quasi-experimental pretest-posttest study without control group conducted in a Paediatric Intensive Care Unit from October 2018 to April 2019 was conducted. A newly hired nursing personnel training programme was first designed and delivered. Later, the participants' self-perception was assessed, as well as their perceived stress and grade of satisfaction using two different Likert scales.

RESULTS

A total of 20 newly hired nurses participated in the study, 90% (n = 18) were female with a median age of 25.5 ± 4.53 years. Higher scores were obtained in participants' self-perception before and after the theoretical training. Lower significant median scores of the participants' stress perception were found (6.9 ± 1.57 versus 5.6 ± 1.794). In the practical part of the programme, we obtained higher scores in all items, as well as lower median scores in stress perception (6.4 ± 1.73 versus 5.6 ± 1.93).

CONCLUSIONS

A theoretical and practical programme for newly hired nursing personnel in a Paediatric Intensive Care Unit improved participants' self-perception and reduced their perceived median scores in stress levels.

Exploring the factors that influence trauma team activation in emergency department staff

Regional trauma networks enable the rapid and safe management and transfer of patients with traumatic injury between designated trauma units and one of 27 major trauma centres throughout the UK. Multispecialty trauma teams are available 24 hours a day, seven days a week, and are activated immediately upon receipt of a patient presenting with major trauma. With most serious trauma patients going direct to major trauma centres rather than a less specialised hospital-based trauma unit, it can be challenging for hospital-based trauma unit staff to gain experience and skill in this area, leading to potential inconsistencies in the process of activating the trauma team. The aim of this service evaluation was to identify factors influencing the decision to activate the trauma team in emergency department (ED) staff working within a 700-bed trauma unit. A questionnaire was sent to 107 staff and 70 completed it, a response rate of 65%. Results indicated that shortfalls in trauma-specific training, lack of clinical experience, undefined roles and responsibilities, department culture, ambulance handover, knowledge of clinical guidelines and previous experience of trauma team activation all affected the decision to activate the trauma team. Trauma-specific training and the support of senior staff could enhance confidence and appropriate trauma team activation rates.

A Study on the Status and Contributory Factors of Adverse Events Due to Negligence in Nursing Care

BACKGROUND

Patient safety issues in medical institutions have received worldwide attention. Nurses play a pivotal role in providing health care at the bedside and the interception of adverse events (AEs). A knowledge of contributory factors for these AEs is vital to individuals, institutional procedures, and also national policy. The goals of this study are to analyze medical litigation related to nursing practice and to determine the most common contributory factors of AEs due to negligence in nursing care.

METHODS

A qualitative content analysis was conducted for AEs related to nursing care to determine the general characteristics and contributory factors. The contributory factors for each case were examined using a modified version of the Yorkshire Contributory Factors Framework.

RESULTS

The most common types of AEs in nursing involved surgeries, procedures/interventions, and medications. The analysis also revealed that situational factors and communication and culture factors contributed most to AEs. Individual staff factors and staff training and education were the most frequent subfactors contributing to AEs.

CONCLUSIONS

Adverse events were associated with various contributory factors that varied according to AE type. Thus, strategies need to be developed based on the understanding of these contributory factors related to the different AE types so that comprehensive approaches to improving patient safety and quality of nursing care can be implemented.

Does continuity in nursing staff matter? A pilot study on correlation of central line-associated bloodstream infections and employee turnover

BACKGROUND

Understaffing has been previously reported as a risk factor for central line-associated bloodstream infections (CLABSI). No previous study addressed the question whether fluctuations in staffing have an impact on CLABSI incidence. We analyzed prospectively collected CLABSI surveillance data and data on employee turnover of health care workers (HCW) to address this research question.

METHODS

In January 2016, a semiautomatic surveillance system for CLABSI was implemented at the University Hospital Zurich, a 940 bed tertiary care hospital in Switzerland. Monthly incidence rates (CLABSI/1000 catheter days) were calculated and correlations with human resources management-derived data on employee turnover of HCWs (defined as number of leaving HCWs per month divided by the number of employed HCWs) investigated.

RESULTS

Over a period of 24 months, we detected on the hospital level a positive correlation of CLABSI incidence rates and turnover of nursing personnel (Spearman rank correlation, r = 0.467, P = 0.022). In more detailed analyses on the professional training of nursing personnel, a correlation of CLABSI incidence rates and licensed practical nurses (Spearman rank correlation, r = 0.26, P = 0.038) or registered nurses (r = 0.471, P = 0.021) was found. Physician turnover did not correlate with CLABSI incidence (Spearman rank correlation, r =  -0.058, P = 0.787).

CONCLUSIONS

Prospectively determined CLABSI incidence correlated positively with the degree of turnover of nurses overall and nurses with advanced training, but not with the turnover of physicians. Efforts to maintain continuity in nursing staff might be helpful for sustained reduction in CLABSI rates.

What nursing sensitive outcomes have been studied to-date among patients cared for in intensive care units? Findings from a scoping review

BACKGROUND

Although many studies have considered mortality and adverse effects as outcomes sensitive to nursing practice, it seems that other outcomes of nursing care in intensive care units have been explored less commonly.

OBJECTIVES

To describe the state-of-science in research in the field of nursing sensitive outcomes in intensive care units and to synthesize outcomes that have been documented to date as being influenced by nursing care.

DESIGN

A scoping review study based on the framework proposed by Arksey and O'Malley, further refined by the Levac and Joanna Briggs Institute was performed in 2019.

DATA SOURCES

The Medline, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, and Google Scholar electronic databases were searched. In addition, the reference list of included articles was screened.

REVIEW METHODS

Two researchers independently identified publications on the basis of the following criteria: (a) articles that reported nursing sensitive outcomes on critically-ill adult patients admitted to the intensive care unit, (b) as primary and secondary studies, (c) written in English, and (d) without any time frame limitation.

RESULTS

Of the 4,231 records, 112 fully met the inclusion criteria and were included. Publications were mainly authored in the US and Canada (n = 44, 39.2%), and the majority (n = 62, 55.3%) had an observational design. A total of 233 nursing sensitive outcomes emerged, categorized in 35 outcomes, with, on average, two per study included. The most often measured outcomes were pressure ulcers (20 studies) and ventilator-associated pneumonias (19 studies); the less studied outcomes were quality of life, secretion clearance, patient-ventilator dysynchrony, and post-extubation dysphagia. When categorizing outcomes, the ones concerning safety (n = 77, 33.1%) were represented the most, followed by those concerning the clinical (n = 72, 30.9%), functional (n = 70, 30.0%), and perceptual (n = 14, 6.0%) domains. The interdependent outcomes linked to multi-professional interventions (e.g., ventilator-associated pneumonias) were the most frequently studied nursing sensitive outcomes (n = 20, 57.1%), while independent outcomes resulting from autonomous interventions performed by nurses were less often studied (n = 8, 22.9%).

CONCLUSIONS

From a clinical point of view, a large heterogeneity of outcomes influenced by nursing care emerged. However, identified outcomes have been studied with different approaches and metrics, so that future efforts will need to establish homogeneous conceptual and operative definitions. Moreover, increasing efforts in establishing perceptual outcomes, or those close to the fundamentals of nursing care, are suggested in order to better depict the contribution of critical care nurses in the field.

Perspectives on strained intensive care unit capacity: A survey of critical care professionals

Background

Strained intensive care unit (ICU) capacity represents a supply-demand mismatch in ICU care. Limited data have explored health care worker (HCW) perceptions of strain.

Methods

Cross-sectional survey of HCW across 16 Alberta ICUs. A web-based questionnaire captured data on demographics, strain definition, and sources, impact and strategies for management.

Results

658 HCW responded (33%; 95%CI, 32–36%), of which 452 were nurses (69%), 128 allied health (19%), 45 physicians (7%) and 33 administrators (5%). Participants (agreed/strongly agreed: 94%) reported that strain was best defined as “a time-varying imbalance between the supply of available beds, staff and/or resources and the demand to provide high-quality care for patients who may become or who are critically ill”; while some recommended defining “high-quality care”, integrating “safety”, and families in the definition. Participants reported significant contributors to strain were: “inability to discharge ICU patients due to lack of available ward beds” (97%); “increases in the volume” (89%); and “acuity and complexity of patients requiring ICU support” (88%). Strain was perceived to “increase stress levels in health care providers” (98%); and “burnout in health care providers” (96%). The highest ranked strategies were: “have more consistent and better goals-of-care conversations with patients/families outside of ICU” (95%); and “increase non-acute care beds” (92%).

Interpretation

Strain is perceived as common. HCW believe precipitants represent a mix of patient-related and operational factors. Strain is thought to have negative implications for quality of care, HCW well-being and workplace environment. Most indicated strategies “outside” of ICU settings were priorities for managing strain.

Heart rate variability can clarify students' level of stress during nursing simulation

Simulation is regarded as an effective educational method for the delivery of clinical scenarios. However, exposure to unfamiliar environments during simulation can cause excessive stress among students, possibly leading to unnatural speech/behavior and poor skill learning (Yerkes-Dodson’s law). Thus, assessing students’ stress in a simulation can provide educators with a better understanding of their mental state. This study sought to clarify stress changes throughout the progression of the simulation by measuring heart rate variability and students’ subjective reactions in 74 nursing students. Heart rate variability was calculated in terms of its high-frequency (HF) and low-frequency/high-frequency (LF/HF) components during 4 phases—the break, patient care, reporting, and debriefing. Students were interviewed about stress experienced during the simulation. The results showed that HF decreased significantly from the break to the patient care and reporting phases. Furthermore, LF/HF increased significantly from the break to the reporting phases. Approximately 55 students felt stressed during the simulation, 24 of whom felt most stressed during the reporting phase. Therefore, the reporting phase involved high objective and subjective stress. It may be possible that the educator’s evaluative attitude increased students’ stress. Therefore, a stress intervention during the reporting phase might further improve students’ performance during that phase. The debriefing phase did not significantly differ from the break phase for objective stress, and students did not report feeling stressed. Thus, in this phase, they were released from the stress of the reporting phase and the unfamiliar environment. During this phase, they might be able to learn what they could not understand owing to high stress in the patient care and reporting phases. This study provides objective and subjective evidence of students’ stress during simulation, and indicates the necessity of providing support during the reporting phase and the importance of debriefing when using clinical scenarios for teaching clinical skills.

Medication Errors and Trainees: Advice for Learners and Organizations

Limited information exists regarding medication errors and trainees (students or residents). Yet during the experiential education component of their training, learners are expected to assume significant responsibilities in the medication use process. This commentary addresses both trainees and organization leaders on medication safety practices and the incorporation of learners into the organization's medication safety culture.

Healthcare Provider Perceptions of Causes and Consequences of ICU Capacity Strain in a Large Publicly Funded Integrated Health Region: A Qualitative Study

OBJECTIVES

Discrepancy in the supply-demand relationship for critical care services precipitates a strain on ICU capacity. Strain can lead to suboptimal quality of care and burnout among providers and contribute to inefficient health resource utilization. We engaged interprofessional healthcare providers to explore their perceptions of the sources, impact, and strategies to manage capacity strain.

DESIGN

Qualitative study using a conventional thematic analysis.

SETTING

Nine ICUs across Alberta, Canada.

SUBJECTS

Nineteen focus groups (n = 122 participants).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Participants' perspectives on strain on ICU capacity and its perceived impact on providers, families, and patient care were explored. Participants defined "capacity strain" as a discrepancy between the availability of ICU beds, providers, and ICU resources (supply) and the need to admit and provide care for critically ill patients (demand). Four interrelated themes of contributors to strain were characterized (each with subthemes): patient/family related, provider related, resource related, and health system related. Patient/family-related subthemes were "increasing patient complexity/acuity," along with patient-provider communication issues ("paucity of advance care planning and goals-of-care designation," "mismatches between patient/family and provider expectations," and "timeliness of end-of-life care planning"). Provider-related factor subthemes were nursing workforce related ("nurse attrition," "inexperienced workforce," "limited mentoring opportunities," and "high patient-to-nurse ratios") and physician related ("frequent turnover/handover" and "variations in care plan"). Resource-related subthemes were "reduced service capability after hours" and "physical bed shortages." Health system-related subthemes were "variable ICU utilization," "preferential "bed" priority for other services," and "high ward bed occupancy." Participants perceived that strain had negative implications for patients ("reduced quality and safety of care" and "disrupted opportunities for patient- and family-centered care"), providers ("increased workload," "moral distress," and "burnout"), and the health system ("unnecessary, excessive, and inefficient resource utilization").

CONCLUSIONS

Engagement with frontline critical care providers is essential for understanding their experiences and perspectives regarding strained capacity and for the development of sustainable strategies for improvement.

Evaluation of a High-Fidelity Simulation Training Program for New Cardiothoracic Intensive Care Unit Nurses

The objective of this article is to evaluate the effect of a high-fidelity simulation training program on knowledge and confidence as part of a nursing internship in the cardiothoracic intensive care unit. Ten nurse interns each completed a simulation scenario involving common postoperative complications followed by a group debriefing session. Knowledge and confidence were assessed using a multiple-choice test and modified self-efficacy scale, respectively. Both were administered precourse and postcourse and again 2 weeks later. The simulation effectiveness tool, a 0-2 scale with higher scores indicating higher degree of perceived effectiveness, was used to evaluate participants׳ perceptions of the program. Paired t-tests compared precourse and postcourse scores as well as postcourse and follow-up scores for both knowledge and confidence. Spearman rho compared subjective with objective assessment of learning and improvement in learning with improvement in confidence. Mean knowledge scores improved from 48.18% (standard deviation [SD] = 14.7) to 60.9% (SD = 22.6; P < 0.05) and confidence scores improved from 20.8 (SD = 5.17) to 25.9 (SD = 3.3; P < 0.05), both with insignificant changes 2 weeks later. The simulation effectiveness tool mean score was 1.64 (SD = 0.56). There was no correlation between the objective and subjective learning assessments or between the improvement in learning and improvement in confidence. The inclusion of a high-fidelity simulation course showed improvement in both learning and confidence among the new graduate nurses; however, objective assessment of learning is needed. It is also important to note that an improvement in confidence may not indicate an improvement in actual ability.

Technologies in intensive care: causes of adverse events and implications to nursing

Objective:

to identify the causes of adverse events affecting clients resulting from the use of equipment in intensive care services; to point out the main recommendations for clinical practice to minimize these events and, then, discuss the implications to nursing care.

Method:

integrative and descriptive review on the SciELO, Medline, LILACS, and PubMed databases. Articles were selected based on the inclusion criteria and the structured instrument was applied.

Results:

altogether, 11 articles were selected where three evidence units were outstanding: Equipment failure; inadequate use of equipment; and team failure. Permanent education of professionals; evaluation of production and availability of equipment; and use of checklists are recommended.

Conclusion:

preventing adverse events related to equipment is one of the nursing responsibilities and requires the establishment of defensive barriers to prevent these.

Intensive care nurses' practice related to experience and shift worked

OBJECTIVE

To analyse the social representations of nurses about intensive care practices comparing the variables 1) time since graduation and 2) shift worked.

METHOD

Qualitative field research using social representation theory. Individual interviews were conducted and lexical analysis was applied.

STUDY SETTING

Intensive Care Unit of a federal hospital with 21 clinical nurses.

FINDINGS

Day shift nurses are more pragmatic and operationally oriented because they deal directly with the general functioning of the unit. Less experienced nurses face difficulties dealing with intensive care contexts, but have a critical view of their practices, while more experienced nurses apply practical knowledge in their decision-making and actions.

CONCLUSION

The relationship of proximity or distance from patients, mediated by technology, is related to the domains of knowledge that are required to manage technology and to the role technology plays in intensive care.

The effect of high-fidelity simulation on knowledge and confidence in critical care training: An integrative review

Patient outcomes in critical care have long been linked to provider experience, but with older providers retiring, it is becoming difficult to maintain a high-level of experience among the ICU staff. Innovative training methods that improve providers' knowledge and confidence may be able to make up for deficiencies in clinical experience. High-fidelity simulation training mimics clinical experience and has been extensively studied in the training of procedural skills, but what is the effect of this type of training on knowledge and confidence? To answer this question, we conducted a review of the literature for studies examining the effect of simulation training on knowledge and confidence among critical care providers. Seventeen papers were identified that met the inclusion criteria and a systematic approach was used to review the papers and synthesize the data. All 17 studies demonstrated an improvement in knowledge and while only 13 of the included studies examined the effect on provider confidence, all found an improvement. We conclude that high-fidelity simulation is a useful tool for improving knowledge and confidence among critical care providers and merits consideration for inclusion in critical care training programs.

Nutritional care of elderly patients in acute care settings: A qualitative study

AIM

Poor nutritional status is common in older adult patients. The present study aimed to explore barriers and facilitators to nutritional care of elderly patients in acute care settings.

METHODS

Data were collected through individual face-to-face interviews with 12 registered nurses, and analyzed using interpretive description methodology.

RESULTS

Two core themes emerged from the analysis of data: (i) neglected care, with three subthemes of "support but also independence," "unsupportive environment" and "responsibility of the family;" and (ii) a humanitarian ethic, with two subthemes of "respect and dignity" and "humanitarian care."

CONCLUSIONS

As an integral part of holistic care, elderly patient nutrition should be emphasised in health professional education, and promoted through managerial support, multidisciplinary collaborations, and implementation of appropriate monitoring and evaluation systems.

Medical error, disclosure and patient safety: a global view of quality care

Medical errors are a prominent issue in health care. Numerous studies point at the high prevalence of adverse events, many of which are preventable. Although there is a range of severity in errors, they all cause harm, to the patient, to the system, or both. While errors have many causes, including human interactions and system inadequacies, the focus on individuals rather than the system has led to an unsuitable culture for improving patient safety. Important areas of focus are diagnostic procedures and clinical laboratories because their results play a major role in guiding clinical decisions in patient management. Proper disclosure of medical errors and adverse events is also a key area for improvement. Globally, system improvements are beginning to take place, however, in Canada, policies on disclosure, error reporting and protection for physicians remain non-uniform. Achieving a national standard with mandatory reporting, in addition to a non-punitive system is recommended to move forward.

[Usefulness of failure mode and effects analysis to improve patient safety during the process of incorporating new nurses in an intensive care unit]

OBJECTIVE

To analyze proactively the process of incorporating new nurses in the intensive care unit (ICU) in order to detect risk areas and establish improvements that increase critical patient safety.

MATERIAL AND METHODS

Once the risk area was defined, the different phases of failure mode and effects analysis (FMEA) were applied: work team selection; process design; process phases definition; failure modes, possible causes and effects analysis; risk priority for each failure, and development of ameliorating and corrective actions. The proposed actions consisted of an orientation and training program (theoretical and practical) for new nurses, a supervision plan, a progressive responsibility program and ICU participation in personnel recruitment.

RESULTS

Twelve nurses began to work in the ICU during the first 18 months of the program's implementation. Of these, only one nurse had full experience in critical care and three had partial experience. Participation of the ICU in personnel recruitment was nil. All the nurses with no or partial experience followed the orientation program (nursing supervisor interview, test of previous knowledge, handing over of the employee handbook, etc.), the theoretical and practical training program (supervision and tutorship) and the progressive responsibility program. More than half (63.6%) of the new nurses had another nurse duplicating their jobs during the training period and 54.5% of the new nurses attended the critical care course for nurses. Nurses participating in the orientation and training program expressed a high level of satisfaction. These measures helped nurses to decrease their stress and anxiety, increase and consolidate their knowledge, and provide safer care to critical patients.

CONCLUSIONS

FMEA is a useful tool for improving ICU processes, even those involving human resources. The improvements implemented to decrease clinical risk related to the incorporation of new nurses in the ICU, based on previous training, will increase the safety of critical patient care by decreasing human errors due to inexperience.

Evaluation of the implementation of Assistant in Nursing workforce in haemodialysis units

The aim of this project was to evaluate the introduction of Assistant in Nursing (AINs) in the haemodialysis units at a major tertiary Area Health Service in Sydney, Australia. All nursing staff were asked to complete a baseline and follow-up survey to determine changes to their attitudes to the new skill mix model and their satisfaction with the new organization of care delivery in their dialysis units. Comparison of the baseline and follow-up surveys in the paired data was favourable with nurses acknowledging that they would cope well with the introduction of AINs, and they were more likely to disagree with the statement that their workload would increase after the introduction of AINs in the follow-up survey. There was little difference in (i) the workload of the dialysis units before and during the intervention; and (ii) the incidence of patient and nursed related adverse outcome events.

Interação medicamentosa: conhecimento de enfermeiros das unidades de terapia intensiva

OBJETIVO: Avaliar o conhecimento das interações medicamentosas (IM)de enfermeiros que atuam em unidades de terapia intensiva de adultos, de três hospitais públicos de Goiás. MÉTODOS: Estudo descritivo, transversal. População 64 e amostra, 51 enfermeiros. Construiu-se um instrumento de coleta de dados, utilizando informações da base de dados MICROMEDEX®. RESULTADOS: Sobre o conhecimento de IM e manejo clínico, houve uma relação de acertos e erros de, aproximadamente, 50% dos enfermeiros. As duplas de medicamentos que os enfermeiros mais acertaram foram relativas a medicamentos com ação sedativa e analgésica e as que apresentaram mais erros, foram as de ação anti-infecciosa e anti-hipertensiva. CONCLUSÃO: É necessário sensibilizar autoridades e profissionais sobre a importância das IM na UTI e implementar ações para a segurança dos pacientes na terapêutica medicamentosa.

ICU staffing and patient outcomes: more work remains

Many studies have demonstrated that closed intensive care units (ICUs), staffed by trained intensivists, are associated with improved patient outcomes. However, the mechanisms by which ICU organizational factors, such as physician staffing, influence patient outcomes are unclear. One potential mechanism is the increased utilization of evidence-based practices in closed ICUs. Cooke and colleagues investigated this hypothesis in a cohort of 759 acute lung injury patients in 23 ICUs in King County, Washington, USA. Although closed ICUs were independently associated with a modestly lower mean tidal volume, this finding did not explain the mortality benefit associated with a closed ICU model in this patient cohort. Future studies should evaluate other potential mechanisms by which closed ICUs improve patient outcomes. An improved understanding of these mechanisms may yield new targets for improving the quality of medical care for all ICU patients.

The experiences of health care workers employed in an Australian intensive care unit during the H1N1 Influenza pandemic of 2009: a phenomenological study

BACKGROUND

The H1N1 Influenza A pandemic arrived in Australia in early May 2009. In Queensland, the highest number of H1N1 cases were admitted to the intensive care unit when compared with the other Australian states. While many recent studies examining the H1N1 pandemic have focussed on service delivery and disease epidemiology, few have explored the lived experiences of frontline health care workers caring for the patients in the intensive care unit.

OBJECTIVES

The purposes of this study were to: document and describe the lived experiences of the nursing and medical staff caring for patients in the intensive care unit during the H1N1 pandemic; to validate the staffs' experiences; and to assist in informing future pandemic planning by highlighting the collective experiences of these frontline health care workers.

DESIGN

A phenomenological study method was used.

SETTING AND PARTICIPANTS

34 staff from a tertiary referral hospital in Brisbane, Australia participated in the study.

METHODS

Data was collected using an open ended questionnaire and focus groups. The resulting responses were analysed using Colaizzi's framework to discover regular patterns of meaning that emerged.

RESULTS

Eight common themes emerged: the wearing of personal protective equipment; infection control procedures; the fear of contracting and transmitting the disease; adequate staffing levels within the intensive care unit; new roles for staff; morale levels; education regarding extracorporeal membrane oxygenation; and the challenges of patient care. These eight themes articulate the lived experience of the staff during the height of the H1N1 Influenza pandemic period.

CONCLUSIONS

Planning for a pandemic situation is invariably difficult due to the unpredictable nature of the event itself. Recommendations for future pandemic planning which can be drawn from this study include the appointment of a dedicated infection control representative to provide information and support regarding infection control matters; the maintenance of effective communication channels is crucial; and the increased staffing requirements across nursing, medical, allied health and ancillary staff to cope with the higher patient numbers and acuity must be anticipated and planned for.

Quality of practice in an intensive care unit (ICU): a mini-ethnographic case study

BACKGROUND

Nurses' perspectives of maintaining quality practice is important in the context of today's safety and quality agenda. This study provides a snapshot of registered nurses' perspectives on practice quality in one Australian ICU.

METHODS

A mini-ethnographic case study examined how quality is embedded in the culture of ICU nursing. Semi-structured interviews of 10 informants were analysed using Spradley's (Spradley JP. The ethnographic interview. Sydney: Holt, Rinehart and Winston, Inc.;1979) ethnographic guidelines.

FINDINGS

Three major themes influenced nursing quality: maintaining cohesiveness in a complex and stressful environment; rapid, effective and respectful communication; and specialist knowledge gained through experience and formal learning.

CONCLUSION

The nurses reported satisfaction with the quality of their ICU practice, but revealed factors that could diminish quality and contribute to job dissatisfaction. Given current recruitment and retention issues and the link between satisfaction and retention, it is important to consider this these factors in advancing the knowledge base for workforce planning.

Safety in obstetric critical care

High-profile inquiries in several countries have helped to raise public awareness of safety issues and driven policy change. In obstetric critical care, various publications have highlighted organizational factors, communication, absence of guidelines, failure to follow local protocols, poor documentation and delay in identifying the deteriorating woman as issues. Patient safety in obstetric critical care is paramount because of its complexity and the vulnerability of the critically ill patient to error. The principles of risk management and its various components can be used to make improvements. A framework to achieve this is as follows: building a safety culture; leading and supporting staff; integrating risk management activity; promoting reporting; involving and communicating with patients and the public; learning and sharing safety lessons; and implementing solutions to prevent harm.

The difficult airway in adult critical care

INTRODUCTION

The difficult airway is a common problem in adult critical care patients. However, the challenge is not just the establishment of a safe airway, but also maintaining that safety over days, weeks, or longer.

AIMS

This review considers the management of the difficult airway in the adult critical care environment. Central themes are the recognition of the potentially difficult airway and the necessary preparation for (and management of) difficult intubation and extubation. Problems associated with tracheostomy tubes and tube displacement are also discussed.

RESULTS

All patients in critical care should initially be viewed as having a potentially difficult airway. They also have less physiological reserve than patients undergoing airway interventions in association with elective surgery. Making the critical care environment as conducive to difficult airway management as the operating room requires planning and teamwork. Extubation of the difficult airway should always be viewed as a potentially difficult reintubation. Tube displacement or obstruction should be strongly suspected in situations of new-onset difficult ventilation.

CONCLUSIONS

Critical care physicians are presented with a significant number of difficult airway problems both during the insertion and removal of the airway. Critical care physicians need to be familiar with the difficult airway algorithms and have skill with relevant airway adjuncts.

Evaluation of a nurse consultant's clinical activities and the search for patient outcomes in critical care

AIMS

To describe the actual clinical activities undertaken by a critical care nurse consultant in an eight-bedded adult surgical high dependency unit within a large NHS Teaching Hospitals NHS Trust.

BACKGROUND

In the United Kingdom, the first critical care nurse consultants were approved in 2000 following the Department of Health's (1999) revised career structure for nurses. Expert practice is a core function of the role although the nature of expert practice in the context of critical care is unclear. Expert practice is often deemed to be a feature of advanced practice and although a number of studies have investigated this in context of critical care, there is little insight into the nature of advanced practitioners' clinical practice and how it might influence patient outcome.

DESIGN METHODS

A diary was used by a critical care nurse consultant to record activity during scheduled clinical sessions. Data were collected for four months: 39 sessions were evaluated. Qualitative data were content analysed and coded into categories. Clinical activities were coded, categorized and analysed using SPSS 11.0 for windows (SPSS Inc., Chicago, IL, USA).

FINDINGS

Clinical activities included direct care activities, clinical leadership, education and training. Two main themes emerged from the qualitative data and were categorized as clinical reasoning and clinical instruction. Clinical activities arising from clinical reasoning and clinical instruction were aimed at minimizing risk and the provision of quality care. In doing this, one of the outcomes was the detection and resolution of untoward clinical occurrences.

CONCLUSION

The level of achievement--or end point--of clinical activities was that the patient was established in 'a state free from risk or harm that optimises rehabilitation'. 'A state free from risk or harm that optimizes rehabilitation' might be one outcome reflecting the needs of individual critically ill patients that is sensitive to individual nursing contribution.

RELEVANCE TO CLINICAL PRACTICE

There is increasing pressure on health-care professionals to identify and measure their individual impact on the outcome of patients. This study adds further insight into the complexities associated with evaluating the influence of individual contribution on patient outcome, especially when it is characterized by complex processes involving clinical judgement and decision-making.

Matching nurse skill with patient acuity in the intensive care units: a risk management mandate

AIM

This paper aims to highlight the need for the traditional concept of nursing skill mix to be reconfigured within a new concept of skill matching.

BACKGROUND

Substantive literature describes staff deployment and patient-dependency models. However, limited information exists as to what informs decision making regarding nurse skill assessment and subsequent patient allocation in intensive care units.

KEY ISSUES

In intensive care units, nurse numbers, available nursing skills and patient allocation decisions, impact directly on care provision and outcomes. This paper argues that staffing decisions that are based on insufficient knowledge which lack consideration of all pertinent factors result in poor 'skill matching', potential adverse events and poor outcomes. A critical inextricable link exists between staffing decisions, patient safety and risk in the intensive care unit. Use of a multifactorial skill-matching approach within a dedicated staffing decision-support system is recommended.

CONCLUSION

This commentary paper adds a new perspective to nurse-staffing decision practices and their relationship to risk management in the intensive care unit and offers a new research direction.

Team model: Advocating for the optimal method of care delivery in the intensive care unit

OBJECTIVE

To review published data on the team model of intensive care unit (ICU) care delivery.

DESIGN

Nonexhaustive, selective literature search.

SETTING

Review of literature published in the English language.

PATIENTS/SUBJECTS

Humans cared for in ICUs.

INTERVENTIONS

None.

RESULTS

The team model for delivery of ICU care reduces mortality, ICU length of stay, hospital length of stay, and cost of care. Convincing data suggest that merely having daily rounds led by an intensivist enhances patient care significantly. Further improvements can be obtained by maintaining a nurse-to-patient ratio of no greater than 1:2, adding critical care pharmacists, and providing dedicated respiratory therapists to the ICU team.

CONCLUSION

Current and looming shortages of all ICU healthcare providers is a barrier to universal implementation of the team model. Advocating for the ICU team model for critical care delivery requires local, regional, national, and international activities for success.

Improving the ICU: part 1

ICUs are a vital component of modern health care. Improving ICU performance requires that we shift from a paradigm that concentrates on individual performance to a different paradigm that emphasizes the need to assess and improve ICU systems and processes. This is the first part of a two-part treatise. It discusses existing problems in ICU care, and the methods for defining and measuring ICU performance.

Projected incidence of mechanical ventilation in Ontario to 2026: Preparing for the aging baby boomers*

OBJECTIVE

The aging baby boomers are expected to have a significant impact on the healthcare system. Mechanical ventilation is an age-dependent, costly, and relatively nondiscretionary medical service that may be particularly affected by the aging population. We forecast the future incidence of mechanical ventilation to the year 2026 to understand the impact of aging baby boomers on critical care resources.

DESIGN

Population-based, sex-specific, and age-specific mechanical ventilation incidences for adults for the year 2000 were directly standardized to population projections to estimate the incidence of mechanical ventilation, in 5-yr intervals, from 2006 to 2026. Sensitivity analyses were performed by varying population projections and mechanical ventilation incidence for the elderly.

SETTING

Province of Ontario, Canada.

PATIENTS

Noncardiac surgery, mechanically ventilated adults.

INTERVENTIONS

None.

MAIN RESULTS

The projected number of ventilated patients in 2026 was 34,478, representing an 80% increase from 2000. The crude incidence increased 31%, from 222 to 291 per 100,000 adults. The annually compounded projected growth rate during this 26-yr period was 2.3%, similar to the actual growth rate experienced in the 1990s. The projected incidence was relatively insensitive to changes in assumptions, with estimates for 2026 ranging from 31,473 to 36,313 ventilated adults.

CONCLUSIONS

The incidence of mechanical ventilation projected to the year 2026 will steadily increase and outpace population growth as occurred in the 1990s. In the current environment in which intensive care unit resources are limited and ventilated patients already use a significant proportion of acute care resources, planning for this continued growth is necessary. Existing evidence-based strategies that improve both the efficiency and efficacy of critical care services should be carefully evaluated for widespread implementation.

Medical errors: impact on clinical laboratories and other critical areas

The Institute of Medicine (IOM) report (1999) stated that the prevalence of medical errors is high in today's health care system. Some specialties in health care are more risky than others. A varying blunder/error rate of 0.1-9.3% in clinical diagnostic laboratories has been reported in the literature. Many of these errors occur in the preanalytical and postanalytical phases of testing. It has been suggested that the errors occurring in clinical diagnostic laboratories are smaller in number than those occurring elsewhere in a hospital setting. However, given the quantum of laboratory tests used in health care, even this small rate may reflect a large number of errors. The surgical specialties, emergency rooms, and intensive care units have been previously identified as areas of risk for patient safety. Though the nature of work in these specialties and their interdependence on clinical diagnostic laboratories presents abundant opportunities for error-generating behavior, many of these errors may be preventable. Appropriate attention to system factors involved in these errors and designing intelligent system approaches may help control and eliminate many of these errors in health care.

A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS)*

OBJECTIVE

To evaluate the contributing and limiting factors for airway events reported in the Intensive Care Unit Safety Reporting System (ICUSRS) developed in partnership with the Society of Critical Care Medicine.

DESIGN

Analysis of system factors in airway vs. nonairway events reported to a voluntary, anonymous, Web-based patient safety reporting system (the ICUSRS).

SETTING

Sixteen adult and two pediatric intensive care units (ICU) across the United States.

PATIENTS

Incidents reported during the 12-month period ending June 30, 2003.

INTERVENTIONS

None

MEASUREMENTS

Descriptive characteristics of incidents (defined as events that could have, or did, cause harm), patients, and patient harm; separate multivariable logistic regression analyses of contributing and limiting factors for airway vs. nonairway events.

MAIN RESULTS

There were 78 airway and 763 nonairway events reported. More than half of airway events were considered preventable. One patient death was attributed to an airway event. Physical injury, increased hospital length of stay, and family dissatisfaction occurred in at least 20% of airway events. Important factors contributing to reported airway events (odds ratio (OR), 95% confidence interval (CI)) included patients' medical condition (5.24, 3.07-8.95) and age <1 yr old (4.15, 1.79-9.59). Factors limiting the impact of airway events (OR, 95% CI) included adequate ICU staffing (3.60, 1.71-7.56) and use of skilled assistants (3.20, 1.62-6.32).

CONCLUSIONS

Patients are harmed by unintended and preventable incidents involving airway management. Prevention efforts should focus on critically ill infants and patients with complex medical conditions. Managers should ensure appropriate ICU staffing to limit the impact of airway events when they occur.