Incidence, characteristics, and associated factors of pressure injuries acquired in intensive care units over a 12-month period: A secondary analysis of a quality improvement project

OBJECTIVES

To determine the 12-month cumulative incidence, characteristics, and associated factors of pressure injuries acquired in Intensive Care Units.

SETTING

Four intensive care units in a Norwegian University Hospital.

RESEARCH METHODOLOGY

A prospective observational cohort study using data from daily skin inspections during a quality improvement project. We used descriptive statistics and logistic regression. Variables associated with the development of intensive care unit-acquired pressure injuries are presented with odds ratios (OR), and 95% confidence intervals.

RESULTS

The 12-month cumulative incidence of patients (N = 594) developing intensive care unit-acquired pressure injuries was 29 % (172/594) for all categories and 16 % (95/594) when excluding category I pressure injuries (no skin loss). Cumulative incidence for patients acquiring medical device-related pressure injuries was 15 % (91/594) and 11 % (64/594) for category II or worse. Compression stockings (n = 51) and nasogastric tubes (n = 22) were the most frequent documented medical devices related to pressure injuries. Development of pressure injuries category II or worse was significantly associated with vasoactive drug infusions (OR 11.84, 95 % CI [1.59; 88.13]) and longer intensive care unit length of stay (OR 1.06, 95 % CI [1.04; 1.08]).

CONCLUSION

The 12-month cumulative incidence of intensive care unit-acquired pressure injuries was relatively high when category I pressure injuries were included, but comparable to other studies when category I was excluded. Some medical device-related pressure injuries were surprisingly frequent, and these may be prevented. However, associated factors of developing pressure injuries were present and deemed non-modifiable.

IMPLICATIONS FOR CLINICAL PRACTICE

Awareness about pressure injury prevention is needed in the intensive care unit considering high incidences. Nurses can detect category I pressure injuries early, which may be reversed. Our findings show several factors that clinicians can control to reduce the risk of pressure injuries in the intensive care unit.

Patient mobilisation in the intensive care unit and evaluation of a multifaceted intervention including Facebook groups: A quasi-experimental study

AIMS

To describe prevalence and time to mobilisation in intensive care unit patients defined as a minimum sitting in an upright position in bed, and evaluate the impact of a multifaceted quality improvement campaign on likelihood of patients being mobilised.

RESEARCH METHODOLOGY/DESIGN

Quality improvement project using a quasi-experimental study design, comparing patient cohorts before (Before) and after (Intervention) a campaign including educational sessions, audit and feedback of intensive care unit quality indicators via closed Facebook-groups and e-mail and local opinion leaders. Secondary analysis of mobilisation data from adult intensive care patient stays extracted from electronical medical charts. Likelihood of being mobilised was analysed with Multivariate Cox-regression model and reported as Sub-hazard Ratio (SHR).

SETTING

Four intensive care units in a university hospital.

MAIN OUTCOME MEASURES

Prevalence and time to first documented mobilisation, defined as at least "sitting in bed" during the intensive care unit stay.

RESULTS

Overall, 929 patients were analysed, of whom 710 (76 %) were mobilised; 73 % (356/ 489) in Before vs 81 % (354/ 440) in Intervention (p = 0.007). Median time to mobilisation was 69.9 (IQR: 30.0, 149.8) hours; 71.7 (33.9, 157.9) in Before and 66.0 (27.1, 140.3) in Intervention (p = 0.104). Higher SAPS II-scores were associated with lower likelihood (SHR 0.98, 95 % CI 0.97-0.99), whereas admissions due to gastroenterological failure (SHR 2.1, 95 % CI 1.4-3.0), neurological failure (SHR 1.5, 95 % CI 1.0-2.2) and other causes (intoxication, postoperative care, haematological-, and kidney failure) (SHR 1.7, 95 % CI 1.13-2.6) were associated with higher likelihood of mobilisation vs respiratory failure.

CONCLUSION

A quality improvement campaign including use of Facebook groups is feasible and may improve mobilisation in intensive care unit patients. Most patients were mobilised within 72 hours following intensive care unit admission, and SAPS II scores and causes for intensive care unit admission were both associated with likelihood of being mobilised.

Documentation for Assessing Pain in Postoperative Pain Management Pre- and Post-intervention

PURPOSE

Although Norwegian law requires the documentation of patients' care processes, including pain assessment, research has shown that the quality of postoperative documentation for assessing pain does not meet an acceptable standard and requires improvement. The purpose of this study was to investigate whether an educational intervention can increase nurses' documentation of postoperative pain assessments, alter patients' opioid consumption, and ensure that patients have at least one documented Numeric Rating Scale (NRS) ≤3 at rest before being discharged. A secondary aim was to investigate whether the nurses' education and experience influenced their pain assessments.

DESIGN

An observational study with a pre-post intervention.

METHODS

The study following a pre-post design involved documenting pain assessments of 304 patients undergoing cancer surgeries in a postoperative unit at the Norwegian Radium Hospital, Oslo University Hospital. In an educational intervention, two 45-minutes teaching sessions within two weeks, addressed validated pain assessment tools and the documentation of pain assessment. Descriptive frequency analysis and partial correlation with Pearson's r - value were used, with P < .05 indicating significance.

FINDINGS

Postintervention, pain assessments in general increased significantly from a mean of two times per patient to three times. Overall, the use of assessment tool Critical -Care Pain Observation Tool increased from 6.1% to 25.8%, opioid consumption increased in mean from 3.34 to 4.79 in milligram and the documentation at discharge increased from 81.4% to 91.4%. The documentation of nurses with more than 10 years' experience in the unit especially improved from 17.5% to 31.7%.

CONCLUSIONS

Educational intervention and reminders about basic systematic pain assessment and the evaluation of pain measures improved nurses' documentation of postoperative pain management and documentation at discharge. The findings underscore the importance of regularly ensuring the quality of patients' treatment by systematically documenting nurses' clinical tasks and the outcome of patients' care.

«Lite visste vi hvordan vårsemesteret 2020 ville bli» – en tverrsnittstudie om pandemiens innvirkning på intensivsykepleiestudentenes opplevelser i vårsemesteret 2020

Bakgrunn: Midt i vårsemesteret 2020 ble SARS-CoV-2 erklært som pandemi. Studiehverdagen til landets intensivsykepleiestudenter ble brått snudd på hodet. All undervisning ble digital, og det var stor usikkerhet rundt gjennomføringen av praksisstudier. Mangelen på intensivsykepleiere ble tydeliggjort, og utdanning av flere intensivsykepleiere mer kritisk. Hensikt: Hensikten med studien var å kartlegge hvilke erfaringer intensivsykepleiestudentene i masterprogram hadde i vårsemesteret 2020 under covid-19-pandemien i Norge. Metode: Studien er en beskrivende tverrsnittstudie med bruk av spørreskjema. Spørreskjemaet ble testet gjennom en pilotstudie, og sendt ut til alle landets intensivsykepleiestudenter som var i en videreutdanning som tilbød mastergrad. Resultat: Svarprosenten i studien var 29,2 prosent (n = 56). I teoretiske emner oppnådde 75 prosent av studentene sine læringsmål, og i kliniske emner oppnådde 76,8 prosent sine læringsmål. Digital undervisning medførte at 60,7 prosent (n = 34) opplevde svekket studiemotivasjon. Halvparten av studentene opplevde redusert mulighet for veiledning i klinisk praksis, og 64,3 prosent erfarte at de ble brukt som arbeidskraft på praksisstedet. Kun 34 prosent opplevde å få beholde sin studentrolle, og 23,3 prosent tviler på om de vil fortsette i yrket. Konklusjon: Våre resultater viser at første fase av pandemien medførte endringer i undervisning, praksisstudier og veiledning, som medførte lavere læringsutbytte og motivasjon. Flertallet av respondentene oppnådde likevel sine læringsmål i både teoretiske og kliniske emner. Funnene viser at opplevelse av å bli brukt som arbeidskraft i praksis, og tap av studentrolle, er faktorer som reduserer motivasjon til å både gjennomføre studiet og å fortsette i yrket. Studien viser at det å være student i en pandemi er utfordrende fordi pandemien medførte endringer i studenthverdagen. ENGLISH ABSTRACT Little did we know what the spring semester would bring ~ a cross-sectional study on the pandemics impact on the intensive care nursing students’ experiences in the spring semester 2020 Background: The SARS-CoV-2 was declared as a pandemic in the middle of the spring semester of 2020. For Norway’s intensive care nursing students, student life suddenly changed. Lectures became digital and it was uncertain if clinical training could continue. It became evident that there is a shortage of intensive care nurses and that educating more intensive care nurses is critical.  Purpose: The purpose of this study was to map the intensive care nursing students experiences of the Covid-19 pandemic during the spring semester 2020 in Norway. Method: This thesis is a descriptive cross-sectional study using a questionnaire. A pilot group tested the questionnaire before it was sent out to all of Norway’s intensive care nursing students enrolled in a master’s program.  Results: Response rate was 29.2 percent (n = 56). In theoretical classes 75 percent of the students achieved their learning goals and in clinical training 76.8 percent achieved their learning goals. Digital learning caused 60.7 percent (n = 34) of the students to experience reduced study motivation. Half of the students reported experiencing less guidance in clinical training, and 64.3 percent felt they had been used as workforce. Only 34 percent experienced keeping their student role, and finally 23.3 percent are not certain they want to keep working as an intensive care nurse. Conclusion: Our results show that the first phase of the pandemic brought change to lectures, clinical training and guidance from preceptors, which led to diminished learning and motivation. However, the majority of the students achieved their learning goals in both theoretical classes and clinical training. Our results show that feeling like they have been used as workforce and loss of student role reduces their motivation to complete their studies and continue working. This study shows that being a student in a pandemic is challenging because the pandemic brought change to student life. 

Testing the Reliability and Validity of the Nursing Activities Score in Critical Care Nursing

BACKGROUND AND PURPOSE

The purpose of this study was to test the reliability and validity of the conceptual model of critical care nursing using the Nursing Activities Score (NAS) for intensive care unit (ICU) patients.

METHODS

An observational study conducted in 2011 using the NAS scores of 219 patients in Norway. The inter-rater reliability (IRR) was tested by parallel classifications. The validity was explored by an exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA) as the measurement models in the structural equation model.

RESULTS

Within the paired ratings the Spearman's correlation coefficient was 0.39. The EFA results explained 77% of the variance with six factors. The reduced CFA model resulted in a three-factor model: relationship, prevention and treatment.

CONCLUSION

The findings supported the IRR and construct validity of the conceptual model of the NAS.

Association between patient classification systems and nurse staffing costs in intensive care units: An exploratory study

OBJECTIVES

Nurse staffing costs represent approximately 60% of total intensive care unit costs. In order to analyse resource allocation in intensive care, we examined the association between nurse staffing costs and two patient classification systems: the nursing activities score (NAS) and nine equivalents of nursing manpower use score (NEMS).

RESEARCH METHODOLOGY/DESIGN

A retrospective descriptive correlational analysis of nurse staffing costs and data of 6390 patients extracted from a data warehouse.

SETTING

Three intensive care units in a university hospital and one in a regional hospital in Norway.

MAIN OUTCOME MEASURES

Nurse staffing costs, NAS and NEMS.

RESULTS

For merged data from all units, the NAS was more strongly correlated with monthly nurse staffing costs than was the NEMS. On separate analyses of each ICU, correlations were present for the NAS on basic costs and external overtime costs but were not significant. The annual mean nurse staffing cost for 1% of NAS was 20.9-23.1 euros in the units, which was comparable to 53.3-81.5 euros for 1 NEMS point.

CONCLUSION

A significant association was found between monthly costs, NAS, and NEMS. Cost of care should be based on individual patients' nursing care needs. The NAS makes nurses' workload visible and may be a helpful classification system in future planning and budgeting of intensive care resources.

Validation of the nursing workload scoring systems "Nursing Activities Score" (NAS), and "Therapeutic Intervention Scoring System for Critically Ill Children" (TISS-C) in a Greek Paediatric Intensive Care Unit

OBJECTIVES

To assess the reliability and validity of the Greek version of Nursing Activities Score (NAS), and Therapeutic Intervention Scoring System for Critically Ill Children (TISS-C) in a Greek Paediatric Intensive Care Unit (PICU).

RESEARCH METHODOLOGY

A methodological study was performed in one PICU of the largest Paediatric Hospital in Athens-Greece. The culturally adapted and validated Greek NAS version, enriched according to the Norwegian paediatric one (P-NAS), was used. TISS-C and Norwegian paediatric interventions were translated to Greek language and backwards. Therapeutic Intervention Scoring System (TISS-28) was used as a gold standard. Two independent observers simultaneously recorded 30 daily P-NAS and TISS-C records. Totally, 188 daily P-NAS, TISS-C and TISS-28 reports in a sample of 29 patients have been obtained during five weeks. Descriptive statistics, reliability and validity measures were applied using SPSS (ver 22.0) (p ≤ 0.05).

RESULTS

Kappa was 0.963 for P-NAS and 0.9895 for TISS-C (p < 0.001) and Intraclass Correlation Coefficient for all scale items of TISS-C was 1.00 (p < 0.001). P-NAS, TISS-28 and TISS-C measurements were significantly correlated (0.680 ≤ rho ≤ 0.743, p < 0.001). The mean score(±SD) for TISS-28, P-NAS and TISS-C was 23.05(±5.72), 58.14(±13.98) and 20.21(±9.66) respectively.

CONCLUSION

These results support the validity of P-NAS and TISS-C scales to be used in greek PICUs.

The experiences of nurses implementing the Modified Early Warning Score and a 24-hour on-call Mobile Intensive Care Nurse: An exploratory study

AIMS AND OBJECTIVES

To explore experiences of nurses implementing and using the Modified Early Warning Score (MEWS) and a Mobile Intensive Care Nurse (MICN) providing 24-hour on-call nursing support.

BACKGROUND

To secure patient safety in hospital wards, nurses may increase the quality of care using a tool to detect the failure of vital functions. Possibilities for support can be provided through on-call supervision from a qualified team or nurse.

DESIGN

This exploratory qualitative investigation used focus group interviews with nurses from two wards of a university hospital in Norway.

METHODS

A purposive sample of seven registered nurses was interviewed in focus groups. A semi-structured guide and an inductive thematic analysis were used to identify interview themes.

RESULTS

Three themes emerged: (1) experiences with the early recognition of deterioration using the MEWS, (2) supportive collaboration and knowledge transfer between nurses and (3) a "new" precise language using the score for communicating with physicians. The use of scores and support were perceived as improving care for deteriorating patients and for supporting the collaboration of nurses with other professionals.

CONCLUSION

In our study, nurses described increased confidence in the recognition of deteriorating patients and in the management of such situations. The non-critical attitude, supportive communication and interactive learning according to the MICN were essential elements for success.