Implementation of an evidence-based sepsis program in the intensive care unit: evident or not?

Critical Care in Obstetrics: Where are We

Maternal mortality is disastrous news for the society, family, newborn, and the obstetrician. Yet, we all who are care providers to these apparently healthy women carrying another life within them are dumbfounded by the clinical conditions arising due to the pregnancy or the effects of the pregnancy, that it becomes difficult to provide an ideal care to them. The rapid uprising of a condition and the worsening of commonly occurring benign conditions-preeclampsia, hemorrhage, etc., necessitates that all obstetricians are well versed with the physiological changes and should be able to not only provide the best of obstetric care to the mother and the newborn but also perform or assist in performance of life-saving procedures.

Infection prevention and control strategies in the era of limited resources and quality improvement: a perspective paper

This paper aims to describe, using an evidence-based approach, the importance of and the resources necessary for implementing effective infection prevention and control (IPC) programmes. The intrinsic and explicit values of such strategies are presented from a clinical, health-economic and patient safety perspective. Policy makers and hospital managers are committed to providing comprehensive, accessible, and affordable healthcare of high quality. Changes in the healthcare system over time accompanied with variations in demographics and case-mix have considerably affected the availability, quality and ultimately the safety of healthcare. The main goal of an IPC programme is to prevent and control healthcare-associated infections (HAI). Many patient-, healthcare provider-, and organizational factors are associated with an increased risk for acquiring HAIs and may impact both the quality and outcome of patient care. Evidence has been published in support of having an effective IPC programme. It has been estimated that about one-third of HAIs could be prevented if key elements of the evidence-based recommendations for IPC are adequately introduced and followed. However, several healthcare agencies from over the world have reported deficits in the essential resources and components of current IPC programmes. To meet its main goal, staffing, training, and infrastructure requirements are needed. Nevertheless, and given the economic crisis, policy makers and hospital managers may be tempted to not increase or even to reduce the budget as it consumes resources and does not generate sufficient visible revenue. IPC is a critical issue in patient safety, as HAIs are by far the most common complication affecting admitted patients. The significant clinical and health-economic burden HAIs place on the healthcare system speak to the importance of getting introduced effective IPC programmes.

Nursing protocol violations: detect, correct and communicate

AIMS AND OBJECTIVES

The Critical Nursing Situation Index (CNSI) is a checklist to detect nursing protocol violations. The objectives of this study were to determine incidences and severities of nursing protocol violations and to check whether corrective actions were taken.

DESIGN

Prospective observational audit.

METHODS

This study was performed in the Intensive Care Unit of the Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands. The CNSI was applied in the period February 2009 to February 2010 by 14 purpose-trained nurses whose interrater reliability had proved sufficient. The checklist addressed nine domains of nursing care: Basic care, Circulation, Respiration, Digestive tract, Infection, Invasive catheters, Medication, ECMO and Central nervous system. The trained nurses also recorded whether violations were discussed with the bedside nurse, whether they could be corrected; and whether they were justifiable. Protocol violations are justifiable when protocol adherence carries greater risk of harm to the patient.

RESULTS

Protocol violations were identified for 987 of 8107 items (12·2%) checked in 238 observations in 126 patients. The percentage of protocol violations varied from 5% in the Medication domain to 26% in the Digestive tract domain. More than fifty percent (53·4%) of all protocol violations were corrected in the same shift; 22·3% of all protocol violations proved justifiable, however, these were rarely documented (6·4% of cases). Nurses' classification of the severity of the protocol violations was not reliable because linearly weighted kappa varied from 0 to 0·33.

CONCLUSIONS

The CNSI is a useful tool to monitor and correct nursing protocol violations.

RELEVANCE TO CLINICAL PRACTICE

Timely identification and correction of protocol violations will reduce possible adverse events resulting from these violations. Furthermore, this study made us aware that protocol violations may be justifiable in clinical practice provided they are well documented.

Reviewing the effects of an educational program about sepsis care on knowledge, attitude, and practice of nurses in intensive care units

BACKGROUND

The most common complication of hospitalization in intensive care units (ICUs) is infections caused by health care. Although sepsis results in a small percentage of infections, it has a high mortality rate. Intensive care nurses play a critical role in the prevention, early detection, and beginning of therapeutic interventions in patients with sepsis. This study aimed to review the effects of an educational program on knowledge, attitude, and practice of ICU nurses in Shariati Hospital, Isfahan, Iran.

MATERIALS AND METHODS

This was a quasi-experimental study on 64 nurses with at least one year of experience in ICU. The subjects were randomly selected and divided into test and control groups. Scores of knowledge, attitude, and practice of the participants were reviewed through a researcher-made questionnaire before and immediately and three weeks after a one-day workshop.

FINDINGS

Compared to baseline, there were significant increases in mean scores of knowledge, attitude, and practice in the test group immediately and three weeks after the education. Mean scores of knowledge in the test group before and immediately and 3 weeks after the intervention were 64.5, 84.9 and 85.2, respectively. The corresponding values for attitude were 73, 79.7, and 83.3. Mean scores of practice were 81.8, 90.5, and 91.3 before and immediately and 3 weeks after the intervention, respectively. In the control group, mean scores of knowledge before and immediately and 3 weeks after the educational course (which they did not attend) was 63.7, 63.9, and 63.5, respectively. Mean scores of attitude were respectively 72.8, 73.3, and 73.2 at the mentioned intervals. The corresponding values for practice were 82.1, 82.9, and 82.7.

CONCLUSIONS

Training significantly improved levels of knowledge, attitude, and practice of ICU nurses in sepsis care. Therefore, compiling and organizing seminars and continuous basic educational workshops for sepsis care are recommended for health caregivers.

Prevention of nosocomial infections in intensive care patients

BACKGROUND

Changes in patient profile, and in the health care environment, altering socioeconomic conditions and advances in science and information technology challenge the nursing profession, in particular intensive care nursing. All these changes will undoubtedly affect the way we will practice in the (near) future. A comprehensive understanding of these factors is therefore essential if nursing is to meet the challenges presented by tomorrow's critical care environment. Precisely because of the often expensive high-tech evolutions that have occurred at a rapid pace and are to be further expected, a continued focus on the basics of nursing, the core role of care, as well as maintaining confidence in the capacity to deliver safe, high-quality, and evidence-based patient care will increasingly be a challenge to critical care nurses. In particular, basic nursing skills and knowledge remain a key prerequisite in the prevention of nosocomial infections, which is a continuing major complication and threat to intensive care unit patients. However, critical care nurses' knowledge about the evidence-based consensus recommendations for infection prevention and control has been found to be rather poor. It has nevertheless been demonstrated that a meticulous implementation of such preventive bundles may result in significantly better patient and process outcomes. Moreover, many preventive strategies are considered to be easy to implement and inexpensive. As such, a first and critical step should be to increase critical care nurses' adherence to the recommendations of the Centers for Disease Control and Prevention.

AIM

In this article, an up-to-date assessment of evidence-based recommendations for the prevention of nosocomial infections, with special focus on catheter-related bloodstream infections and strategies relevant for nurses working in critical care environments, will be provided. Additionally, we will detail on a number of approaches advocated to translate the internationally accepted consensus recommendations to the needs and expectations of critical care nurses, and to consequently enhance the likelihood of successful implementation and adherence. These steps will help critical care nurses in their striving towards excellence in their profession.

SUMMARY

Intensive care nurses can make a significant contribution in preventing nosocomial infections by assuming full responsibility for quality improvement measures such as evidence-based infection prevention and control protocols. However, as general knowledge of the preventive measures has been shown to be rather poor, nurses' education should include supplementary support from evidence-based recommendations.