ICU 2020: five interventions to revolutionize quality of care in the ICU

The Lived Experiences of Telemedicine Intensive Care Unit Nurses

BACKGROUND

Although nurses are the primary clinicians in telemedicine intensive care units (tele-ICUs), their experiences remain underresearched.

OBJECTIVE

To describe and interpret the lived experiences of tele-ICU nurses.

METHODS

A qualitative, hermeneutical, phenomenological approach based on van Manen's methodology was used to collect and interpret interview data. In-depth interviews were conducted with 11 tele-ICU nurses affiliated with a health system in the northeastern United States. The interviews were intended to elicit direct reports of specific incidents to capture the phenomenological experience. Field observations of the practice setting were conducted to enhance data richness.

RESULTS

The participants were primarily female, aged 34 to 67 years, with 11 to 45 years of nursing experience. The following 4 major themes and 12 subthemes were identified: (1) watching intensively and panoptically, with subthemes (a) affirming unremitting diligence, (b) uncovering virtual knowing, and (c) easing perceptions of intrusion; (2) transcending complex boundaries, with subthemes (a) building trustful collaboration, (b) discerning vigilant interventions, and (c) exercising skillful investigation; (3) transforming nursing practice, with subthemes (a) mastering tact, (b) delineating the critical wholeness, and (c) augmenting safety and quality of care; and (4) developing an e-identity, with subthemes (a) tempering feelings of working in shadows, (b) evolving to the enhanced specialist role, and (c) achieving professional gratification.

CONCLUSIONS

Tele-ICU nurses play a transformative role in nursing practice. These findings have implications for nursing practice, education, health policy, enhancement of the current American Association of Critical-Care Nurses (AACN) Tele-ICU Nursing Practice Model, and future research on ICU telemedicine.

Patient safety incident reporting behavior and its associated factors among healthcare professionals in Hadiya zone, Ethiopia: A facility based cross-sectional study

Background

Incidents affecting patient safety can cause unnecessary injury to a patient. It is generally accepted that incident reporting can improve patient safety. In Ethiopian public hospitals, especially in the Hadiya zone, patient safety-related incidents are commonly witnessed, but there is no evidence of reporting behavior among healthcare professionals.

Purpose

This study aimed to assess patient safety incident reporting behavior and its associated factors among healthcare professionals working in public hospitals in the Hadiya zone, South Nation's, Nationalities, and Peoples' Region, Ethiopia, in 2021.

Method

A cross-sectional study design was employed, among 345 healthcare professionals working in public hospitals in the Hadiya zone from August 1-30, 2021. A simple random sampling technique was used to select study participants, and a structured self-administered questionnaire which is adapted from a Hospital survey on patient safety survey and literature was used to collect the data. The data were entered into a data attraction template prepared using the Epi data software and then exported to the SPSS version 25 software for analysis. Descriptive analyses were conducted to determine the general characteristics and distributions of the data collected. An inferential statistical analysis was conducted using the logistic regression model to identify associations between outcome and predictor variables. The odds ratio with the 95 % confidence interval was used to test the associations between the outcome variable and predictor variables. Finally, statistical significance was set at p-value < 0.05.

Results

From the total of 354 healthcare professionals expected, 334 participants, which gave a response rate of 94.4 %, had completed and returned the questionnaire. The result shows that overall patient safety incident reporting behavior among healthcare professionals was 28.7 % (95 % Confidence Interval (CI): (24.6, 33.2). Being a nurse professional [Adjusted Odd Ratio (AOR): 5.48, 95 % CI: (1.67, 17.80)], having job training [AOR: 2.87, 95 % CI: (1.46, 6.28)], having a team within the units [AOR=2.79, 95 %CI: (1.23, 6.28)], communication openness [AOR=2.78, 95 %CI: (1.44, 5.37)], and management support [AOR=2.8, 95 %CI; (1.40, 5.60)] were found to factor significantly associated with patient safety incident reporting behaviour.

Conclusion

This study revealed that the incident-reporting behavior among healthcare professionals was low compared to previous studies. Being a nurse professional, having an on -job training, having a team within the unit, communication openness, perception of the time reporting takes, fear of administration sanction and management support were factors associated with their patient safety incident reporting behavior. Managers should focus on patient safety incidents, prepare continuous training programs, and provide open communication to improve patient safety incident reporting.

Incidence and Influencing Factors of Medical Adhesive-Related Skin Injury in Critically Ill Patients

OBJECTIVE

To determine the incidence and influencing factors of medical adhesive-related skin injury (MARSI) among ICU patients.

METHODS

Study authors enrolled patients admitted to two ICUs at a class 3, grade A hospital in Beijing between January and June 2018 in this prospective cohort study. A data collection sheet was designed, and the data were collected by querying the electronic medical record and via direct assessment. Univariate and multivariate logistic regression analyses were performed to identify factors that independently influenced MARSI incidence. The STROBE checklist was used.

RESULTS

In total, 39 of 356 patients (27 men and 12 women with an average age of 61.51 ± 17.49 years) developed MARSI, an incidence of 10.96%. The median time from admission to MARSI occurrence was 26 days. Multivariate logistic regression analysis revealed that the ICU length of stay, Braden Scale score, and mechanical ventilation all independently influenced incidence. The Braden Scale score (odds ratio [OR], 0.758; 95% confidence interval [CI], 0.636-0.904; P < .05) was a protective factor against MARSI, with higher scores indicating lower risk. The ICU length of stay (OR, 1.098; 95% CI, 1.061-1.136; P < .05) and mechanical ventilation (OR, 3.373; 95% CI, 0.889-12.795; P < .05) were independent risk factors for MARSI.

CONCLUSIONS

The incidence of MARSI in ICU patients was relatively high. Awareness of MARSI should be increased among medical staff, and proper skin care should be provided to prevent and treat MARSI effectively.

The Association of ICU Acuity With Adherence to ICU Evidence-Based Processes of Care

BACKGROUND

Admission to high-acuity ICUs has been associated with improved outcomes compared with outcomes in low-acuity ICUs, although the mechanism for these findings is unclear.

RESEARCH QUESTION

The goal of this study was to determine if high-acuity ICUs more effectively implement evidence-based processes of care that have been associated with improved clinical outcomes.

STUDY DESIGN AND METHODS

This retrospective cohort study was performed in adult ICU patients admitted to 322 ICUs in 199 hospitals in the Philips ICU telemedicine database between 2010 and 2015. The primary exposure was ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles. Multivariable logistic regression was used to examine relations of ICU acuity with adherence to evidence-based VTE and stress ulcer prophylaxis, and with the avoidance of potentially harmful events. These events included hypoglycemia, sustained hyperglycemia, and liberal transfusion practices (defined as RBC transfusions prescribed for nonbleeding patients with preceding hemoglobin levels ≥ 7 g/dL).

RESULTS

Among 1,058,510 ICU admissions, adherence to VTE and stress ulcer prophylaxis was high across acuity levels. In adjusted analyses, those admitted to low-acuity ICUs compared with the highest acuity ICUs were more likely to experience hypoglycemic events (adjusted OR [aOR], 1.12; 95% CI, 1.04-1.19), sustained hyperglycemia (aOR, 1.07; 95% CI, 1.04-1.10), and liberal transfusion practices (aOR, 1.55; 95% CI, 1.33-1.82).

INTERPRETATION

High-acuity ICUs were associated with better adherence to several evidence-based practices, which may be a marker of high-quality care. Future research should investigate how high-acuity ICUs approach ICU organization to identify targets for improving the quality of critical care across all ICU acuity levels.

Management of bed availability in intensive care in the context of hospitalization by court order

Objective:

to identify, from the nurse perspective, situations that interfere with the availability of beds in the intensive care unit in the context of hospitalization by court order.

Method:

qualitative exploratory, analytical research carried out with 42 nurses working in adult intensive care. The selection took place by non-probabilistic snowball sampling. Data collected by interview and analyzed using the Discursive Textual Analysis technique.

Results:

three categories were analyzed, entitled deficiency of physical structure and human resources; Lack of clear policies and criteria for patient admission and inadequate discharge from the intensive care unit. In situations of hospitalization by court order, there is a change in the criteria for the allocation of intensive care beds, due to the credibility of professionals, threats of medico-legal processes by family members and judicial imposition on institutions and health professionals.

Conclusion:

nurses defend the needs of the patients, too, with actions that can positively impact the availability of intensive care beds and adequate care infrastructure.

Analysis of Patient Safety Incident reporting system as an indicator of quality nursing in critical care units in KwaZulu-Natal, South Africa

BACKGROUND

Patient Safety Incidents occur frequently in critical care units, contribute to patient harm, compromise quality of patient care and increase healthcare costs. It is essential that Patient Safety Incidents in critical care units are continually measured to plan for quality improvement interventions.

AIM

To analyse Patient Safety Incident reporting system, including the evidence of types, frequencies, and patient outcomes of reported incidents in critical care units.

SETTING

The study was conducted in the critical care units of ten hospitals of eThekwini district, in KwaZulu-Natal, South Africa.

METHODS

A quantitative approach using a descriptive cross sectional survey was adopted to collect data from the registered nurses working in critical care units of randomly selected hospitals. Self-administered questionnaires were distributed to 270 registered nurses of which 224 (83%) returned completed questionnaires. A descriptive statistical analysis was initially conducted, then the Pearson Chi-square test was performed between the participating hospitals.

FINDINGS

One thousand and seventeen (n = 1017) incidents in ten hospitals were self-reported. Of these incidents, 18% (n = 70) were insignificant, 35% (n = 90) minor, 25% (n = 75) moderate, 12% (n = 32) major and 10% (n = 26) catastrophic. Patient Safety Incidents were classified into six categories: (a) Hospital-related incidents (42% [n = 416]); (b) Patient care-related incidents (30% [n = 310]); (c) (Death 12% [n = 124]); (d) Medication-related incidents, (7% [n = 75]); (e) Blood product-related incidents (5% [n = 51]) and (f) Procedure-related incidents (4% [n = 41]).

CONCLUSION

This study's findings indicating 1017 Patient Safety Incidents of predominantly serious nature, (47% considering moderate, major and catastrophic) are a cause for concern.

Ventilator-associated events, not ventilator-associated pneumonia, is associated with higher mortality in trauma patients

BACKGROUND

Ventilator-associated events (VAE), using objective diagnostic criteria, are the preferred quality indicator for patients requiring mechanical ventilation (MV) for greater than 48 hours. We aim to identify the occurrence of VAE in our trauma population, the impact on survival, and length of stay, as compared to the traditional definition of ventilator-associated pneumonia (VAP).

METHODS

This retrospective review included adult trauma patients, who were Washington residents, admitted between 2012 and 2017, and required at least 3 days of MV. Exclusions included patients with Abbreviated Injury Scale head score greater than 4 and burn related mechanisms of injury. We matched trauma registry data with our institutional, physician-adjudicated, and culture-confirmed ventilator event database. We compared the clinical outcomes of ventilator-free days, intensive care unit length of stay, hospital length of stay, and likelihood of death between VAE and VAP.

RESULTS

One thousand five hundred thirty-three trauma patients met criteria; 124 (8.1%) patients developed VAE, 114 (7.4%) patients developed VAP, and 63 (4.1%) patients met criteria for both VAE and VAP. After adjusted analyses, patients with VAE were more likely to die (hazard ratio [HR], 2.86; 95% confidence interval [CI], 1.44-5.68), than those with VAP, as well those patients with neither diagnosis (HR, 2.83; 95% CI, 1.83-4.38). Patients with VAP were no more likely to die (HR, 1.55; 95% CI, 0.91-2.68) than those with neither diagnosis. Patients with VAE had fewer ventilator-free days than those with VAP (HR, -2.71; 95% CI, -4.74 to -0.68).

CONCLUSION

Critically injured trauma patients who develop VAE are three times more likely to die and utilize almost 3 days more MV than those that develop VAP. The objective criteria of VAE make it a promising indicator on which quality indicator efforts should be focused. Future studies should be aimed at identification of modifiable risk factors for VAE and their impact on outcome, as these patients are at high risk for death.

LEVEL OF EVIDENCE

Retrospective cohort study, level III.

Quality assessment of adult intensive care services: application of a tool adjusted to the reality of low-income countries

Objective

To assess the quality of adult intensive care units.

Methods

This population-based, cross-sectional, observational, analytical study evaluated management type in Maranhão, Brazil. An assessment instrument was applied that assigned scores to each service (maximum 124 points). The units were categorized as insufficient (< 50% of the maximum score), typical (≥ 50% and <80% of the maximum score), or sufficient (≥ 80% of the maximum score).

Results

Of the 26 intensive care units in Maranhão, 23 were evaluated; 15 (65.2%) were located in the state capital, and 14 (60.9%) were public. The mean final score was 67.2 (54.2% of the maximum). The worst performance was observed with regard to processes (50.9%) in the units located outside the capital (p = 0.037) and for hospitals with 68 beds or fewer (p = 0.027). The result of the assessment categorized services as a function of the overall total points earned. Specifically, 8 (34.8%) services were assessed as insufficient, 13 (56.5%) were assessed as typical, and 2 (8.7%) were assessed as sufficient.

Conclusion

The majority of the intensive care units in this study were assessed as typical. These services must be better qualified. The priorities are the processes of the units located outside the capital and in small hospitals.

Equipment failure: conducts of nurses and implications for patient safety

OBJECTIVES

To identify equipment failures during handling by nurses and analyze the conduct of the professionals when these failures occur.

METHODS

Descriptive, exploratory and qualitative study, whose field was the intensive care unit of a public institution, and the participants were day nurses that worked providing direct care to patients. Data were produced in 2014 through systematic observation and interviews and were examined with thick description and content analysis.

RESULTS

The outcomes evinced the inadequate functioning of infusion bombs, users' errors related to the design of equipment and problems with batteries of artificial fans. These failures related to the management of equipment in the unit.

FINAL CONSIDERATIONS

It is necessary to strengthen the monitoring systems of safety conditions of equipment in intensive nursing care to prevent incidents.

Handoff communication in intensive care: links with patient safety

Abstract Objective: To gather scientific evidence about ICU handoff practices and their implications on the safety of communication among team members about hospitalized patients. Method: This was an integrative review conducted in the Medline, PubMed, Cinahl and Scopus databases with the descriptors patient handoff, communication, patient safety, critical care, health communication and intensive care unit. The adopted criteria were: full text, in Portuguese or English, in the last 10 years, with level of evidence over IV and compliance to the study question. Fifteen articles were submitted to a structured tool and analysis. Results: There is evidence of incompleteness, absence or errors in handoff information, caused by the lack of standardization and preparation for this activity, generating delayed, incorrect or non-performed procedures. The use of tools reduces the amount of omitted information, side talks, and errors, improving team satisfaction. Final considerations: It is necessary to promote safe communication in handoff, implementing practices that ensure care continuity.

Developing minimum clinical standards for physiotherapy in South African ICUs: A qualitative study

RATIONALE, AIMS, AND OBJECTIVES

Physiotherapists are integral members of the intensive care unit (ICU) team. Clinicians working in ICU are dependent on their own experience when making decisions regarding individual patient management thus resulting in variation in clinical practice. No formalized clinical practice guidelines or standards exist for the educational profile or scope of practice requirements for ICU physiotherapy. This study explored perceptions of physiotherapists on minimum clinical standards that ICU physiotherapists should adhere to for delivering safe, effective physiotherapy services to critically ill patients.

METHOD

Experienced physiotherapists offering a service to South African ICUs were purposively sampled. Three focus group sessions were held in different parts of the country to ensure national participation. Each was audio recorded. The stimulus question posed was "What is the minimum standard of clinical practice needed by physiotherapists to ensure safe and independent practice in South African ICUs?" Three categories were explored, namely, knowledge, skill, and attributes. Themes and subthemes were developed using the codes identified. An inductive approach to data analysis was used to perform conventional content analysis.

RESULTS

Twenty-five physiotherapists participated in 1 of 3 focus group sessions. Mean years of ICU experience was 10.8 years (±7.0; range, 3-33). Three themes emerged from the data namely, integrated medical knowledge, multidisciplinary teamwork, and physiotherapy practice. Integrated medical knowledge related to anatomy and physiology, conditions that patients present with in ICU, the ICU environment, pathology and pathophysiology, and pharmacology. Multidisciplinary teamwork encompassed elements related to communication, continuous professional development, cultural sensitivity, documentation, ethics, professionalism, safety in ICU, and technology. Components related to physiotherapy practice included clinical reasoning, handling skills, interventions, and patient care.

CONCLUSIONS

The information obtained will be used to inform the development of a list of standards to be presented to the wider national physiotherapy and ICU communities for further consensus-building activities.

Point-of-care testing of activated clotting time in the ICU: is it relevant?

BACKGROUND

Over the past 50 years there have been significant advances in both the clinical techniques and equipment used in the intensive care environment. One traditionally used point-of-care test is activated clotting time (ACT), a coagulation test primarily used during cardiopulmonary bypass surgery to monitor the anticoagulation effects of heparin. The ACT test has since emerged into the intensive care environment to guide clinical assessment and management of haemostasis in postoperative cardiac patients.

OBJECTIVES

The aim of this integrative systematic review was to critique the available research evaluating the effectiveness of ACT point-of-care testing in the intensive care unit for adult patients following cardiopulmonary bypass and cardiac surgery and any impacts this may have on nursing care.

METHODS

A systematic search of Medline, CINAHL and PubMed was undertaken.

RESULTS

The search identified five research papers reporting on the use of ACT point-of-care testing in the intensive care unit for adult cardiac surgical patients. Meta-analysis was not performed due to the lack of homogeneity between the papers included.

CONCLUSIONS

There was a lack of clear evidence for the use of the ACT point-of-care test after cardiac surgery in the intensive care environment. This review has highlighted that conventional laboratory tests are generally more accurate and reliable than this point-of-care test in guiding nursing care management.

Outpatient-based physical rehabilitation for survivors of prolonged critical illness: A randomized controlled trial

INTRODUCTION

The physical and psychological impact of critical illness is well documented. Recovery may take many months and is often incomplete. The optimal way of addressing these important sequelae following hospital discharge remains unclear.

METHODS

Single center, randomized controlled trial in patients invasively ventilated for ≥5 days. The treatment group (TG) underwent a 7-week, outpatient-based exercise and education program, with the control group (CG) receiving no intervention during the study period. Primary outcome measures were changes in functional capacity assessed using the cardiopulmonary exercise testing parameters, peak VO2, and anaerobic threshold (AT). Secondary outcome measures were changes in and health-related quality of life assessed using the Short Form 36 version 2 questionnaire. Assessors remained blinded to group allocation.

RESULTS

Sixty-three patients completed the study (target n = 90). Improvements in both peak VO2 and AT were seen in both TG and CG but no significant difference between groups was evident. AT improved by 11.7% in CG (baseline 10.3 ml O2 kg(-1) min(-1), follow-up 11.5 ml O2 kg(-1) min(-1)), and by 14.6% in TG (baseline 10.3 ml O2 kg(-1) min(-1), follow-up 11.8 ml O2 kg(-1) min(-1); ANCOVA p = 0.74). Peak VO2 improved by 14.0% in CG (baseline 13.6 ml O2 kg(-1) min(-1), follow-up 15.5 ml O2 kg(-1) min(-1)), and by 18.8% in TG (baseline 13.8 ml O2 kg(-1) min(-1), follow-up 16.4 ml O2 kg(-1) min(-1); ANCOVA p = 0.68). Significant improvements were seen in both groups for physical component summary scores (PCS) (TG 39.6 versus 31.0; CG 36.1 versus 32.6) and mental component summary scores (MCS) (TG 48.6 versus 38.4; CG 41.3 versus 37.0). The degree of improvement was significantly higher in the treatment group in comparison to control subjects (PCS p = 0.048; MCS p = 0.017). This improvement was most marked in the subgroup ventilated for >14 days.

CONCLUSIONS

A 7-week, outpatient-based exercise and education program resulted in improved health-related quality of life scores but not improved exercise capacity.

Keeping the sickest patients safer: telemedicine and critical care

Telemedicine in critical care offers opportunities to improve quality and safety by connecting bedside care teams with off-site tele-ICU staff using advanced software and continuous remote monitoring technology. This leads to more proactive care, fewer complications, and timely decisions regarding care.