The Relationship Between Uncertainty and Psychological Distress Among Family Caregivers of Patients With Delirium in Intensive Care Units: A Cross-Sectional Survey.

BACKGROUND: Although family caregivers experienced negative psychological symptoms associated with witnessing intensive care unit delirium in their loved ones, there is a lack of clear understanding of how delirium is associated with family caregiver psychological distress. Uncertainty could be a factor contributed to this association. OBJECTIVES: The aim of this study was to examine the relationship between uncertainty and psychological distress among family caregivers of patients with delirium in intensive care units. METHODS: A cross-sectional correlational design was used for this observational study of adult family caregivers of patients admitted to the intensive care unit and who reported witnessing delirium symptoms in their loved ones. Family caregivers completed an electronic survey in January 2022 that consisted of a family caregiver and patient demographic form, the Mishel Uncertainty in Illness Scale-Family Member, and the Kessler Psychological Distress Scale. Descriptive, correlational, and regression statistical analyses were applied. RESULTS: One hundred twenty-one adult family caregivers were enrolled. Family caregivers reported substantial uncertainty (mean, 106.15, on a scale of 31-155) and moderate to severe psychological distress (mean, 31.37, on a scale of 10-50) regarding their witnessing of delirium episodes in their loved ones. Uncertainty was significantly correlated with psychological distress among family caregivers (rs = 0.52, P < .001). Uncertainty significantly predicted psychological distress among family caregivers (regression coefficient, 0.27; P < .001). DISCUSSION: Family caregiver uncertainty was positively associated with psychological distress. This distress can interfere with family caregiver involvement in patient delirium care. These findings are essential to increase critical care nurse awareness and inform the development of nursing interventions to alleviate possible uncertainty and distress.

Low-dose methylprednisolone treatment in critically ill patients with severe community-acquired pneumonia.

PURPOSE: Severe community-acquired pneumonia (CAP) requiring intensive care unit admission is associated with significant acute and long-term morbidity and mortality. We hypothesized that downregulation of systemic and pulmonary inflammation with prolonged low-dose methylprednisolone treatment would accelerate pneumonia resolution and improve clinical outcomes. METHODS: This double-blind, randomized, placebo-controlled clinical trial recruited adult patients within 72-96 h of hospital presentation. Patients were randomized in 1:1 ratio; an intravenous 40 mg loading bolus was followed by 40 mg/day through day 7 and progressive tapering during the 20-day treatment course. Randomization was stratified by site and need for mechanical ventilation (MV) at the time of randomization. Outcomes included a primary endpoint of 60-day all-cause mortality and secondary endpoints of morbidity and mortality up to 1 year of follow-up. RESULTS: Between January 2012 and April 2016, 586 patients from 42 Veterans Affairs Medical Centers were randomized, short of the 1420 target sample size because of low recruitment. 584 patients were included in the analysis. There was no significant difference in 60-day mortality between the methylprednisolone and placebo arms (16% vs. 18%; adjusted odds ratio 0.90, 95% CI 0.57-1.40). There were no significant differences in secondary outcomes or complications. CONCLUSIONS: In patients with severe CAP, prolonged low-dose methylprednisolone treatment did not significantly reduce 60-day mortality. Treatment was not associated with increased complications.

A concept analysis of family caregivers' uncertainty of patient's illness.

AIM: To analyze and examine the concept of uncertainty of the patient's illness among family caregivers. BACKGROUND: Promoting family caregivers' health is significant in nursing. Family caregivers may experience uncertainty related to their loved ones' illness. A lack of clarity exists regarding the uncertainty concept among family caregivers and its implications in nursing. DATA SOURCE: A review of the literature that focused on family caregivers of adult patients using PubMed, CINAHL, and Scopus databases was completed. METHODS: The Walker and Avant framework was applied to identify the attributes, antecedents, and consequences of family caregivers' uncertainty. RESULTS: Eight articles were analyzed. Attributes of family caregivers' uncertainty included the patient's illness probability and family caregivers' perception of the illness. Antecedents included the characteristics of the patient's illness, factors associated with the family caregivers' perception of the illness, and family responsibilities of caregiving. The consequences included family caregivers' emotional, psychological, and financial outcomes. Family caregivers' uncertainty is defined as the perception of the inability to process information regarding the patient's illness trajectory when caring for significant others' illness. CONCLUSIONS: Individuals can perceive uncertainty differently as a patient-facing uncertainty in illness versus a family caregiver facing uncertainty of their loved ones' illness.

Family Caregivers' Experience of Patients With Delirium in Critical Care Units: A State-of-the-Science Integrative Review.

BACKGROUND: Delirium as a sudden cognitive and behavioral change can be traumatic for family caregivers. An understanding of family caregivers' experiences with delirium in their loved one in an intensive care unit (ICU) will help clinicians provide family-centered care. OBJECTIVE: To explore the impact of delirium on, and the needs of, family caregivers of ICU patients with delirium. METHODS: A comprehensive search was done of literature in the PubMed, CINAHL, and Scopus databases published from 2000 to 2020. Primary studies written in English and done in critical care settings were included. Studies that did not focus on the family experience of delirium were excluded. Additional studies were identified by reviewing the reference lists of selected articles. Evidence was synthesized, and common themes were identified. RESULTS: Among 210 studies, 7 were included after irrelevant and duplicate studies had been removed. Findings were categorized as (1) psychological impacts of a patient's delirium on family caregivers and (2) family caregivers' needs. Common psychological impacts included anxiety, depression, concern, fear, anger, uncertainty, shock, insecurity, and disappointment. Family caregivers reported needing informational and emotional support from, and effective communication with, health care professionals. CONCLUSIONS: Family caregivers' health is crucial to ensuring the effectiveness of family engagement in delirium management. Future studies should consider family caregiver characteristics that could be used to predict psychological symptoms when caregivers are exposed to a patient's delirium and explore whether specific types of delirium cause more psychological impacts and needs among family caregivers than other types of delirium cause.

Advocating for a Loved One in the Setting of Uncertainty: A Mixed-Methods Study Among Caregivers of Sepsis Survivors at the Point of a Sepsis Readmission.

BACKGROUND: The trajectory of recovery after sepsis varies. Survivors may have considerable ongoing limitations, requiring a caregiver for a prolonged period. OBJECTIVES: To learn about experiences, quality of life, coping, resilience, and social support of caregiver caring for survivors of sepsis. METHODS: We conducted a convergent mixed-methods study, recruiting informal caregivers of patients who had survived sepsis in the past year and were readmitted to the intensive care unit with sepsis. Individual face-to-face, semistructured interviews and validated surveys on quality of life, coping, caregiver burden, resilience, and social support were administered to caregivers. Interview transcripts were analyzed using content analysis. Surveys were scored and summarized using descriptive statistics. RESULTS: Caregivers were primarily middle-aged, White, and female. Half were spouses of their care recipient. Caregivers reported some deficits in mobility, pain, and anxiety/depression. Coping styles varied, with engaged coping being more prevalent. Most caregivers reported mild to moderate burden, all reported either normal or high resilience levels, and types of social support were similar. However, interviews and survey findings were not always consistent. Major themes that emerged from the analysis included (1) advocating for and protecting their loved one, (2) coping with caregiving, (3) uncertain future, (4) rewards of caregiving, and (5) need to optimize communication with family. DISCUSSION: Caregivers of sepsis survivors are protective of their care recipient and use a variety of strategies to advocate for their loved one and to cope with the uncertainty involved in a new intensive care unit admission. More advocacy and support are needed for this population.

Prolonged Low-Dose Methylprednisolone in Patients With Severe COVID-19 Pneumonia.

BACKGROUND: In hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia, progression to acute respiratory failure requiring invasive mechanical ventilation (MV) is associated with significant morbidity and mortality. Severe dysregulated systemic inflammation is the putative mechanism. We hypothesize that early prolonged methylprednisolone (MP) treatment could accelerate disease resolution, decreasing the need for intensive care unit (ICU) admission and mortality. METHODS: We conducted a multicenter observational study to explore the association between exposure to prolonged, low-dose MP treatment and need for ICU referral, intubation, or death within 28 days (composite primary end point) in patients with severe COVID-19 pneumonia admitted to Italian respiratory high-dependency units. Secondary outcomes were invasive MV-free days and changes in C-reactive protein (CRP) levels. RESULTS: Findings are reported as MP (n = 83) vs control (n = 90). The composite primary end point was met by 19 vs 40 (adjusted hazard ratio [aHR], 0.41; 95% CI, 0.24-0.72). Transfer to ICU and invasive MV were necessary in 15 vs 27 (P = .07) and 14 vs 26 (P = .10), respectively. By day 28, the MP group had fewer deaths (6 vs 21; aHR, 0.29; 95% CI, 0.12-0.73) and more days off invasive MV (24.0 ±â€…9.0 vs 17.5 ±â€…12.8; P = .001). Study treatment was associated with rapid improvement in PaO2:FiO2 and CRP levels. The complication rate was similar for the 2 groups (P = .84). CONCLUSION: In patients with severe COVID-19 pneumonia, early administration of prolonged MP treatment was associated with a significantly lower hazard of death (71%) and decreased ventilator dependence. Treatment was safe and did not impact viral clearance. A large randomized controlled trial (RECOVERY trial) has been performed that validates these findings. Clinical trial registration. ClinicalTrials.gov NCT04323592.

Society of Critical Care Medicine's International Consensus Conference on Prediction and Identification of Long-Term Impairments After Critical Illness.

BACKGROUND: After critical illness, new or worsening impairments in physical, cognitive, and/or mental health function are common among patients who have survived. Who should be screened for long-term impairments, what tools to use, and when remain unclear. OBJECTIVES: Provide pragmatic recommendations to clinicians caring for adult survivors of critical illness related to screening for postdischarge impairments. PARTICIPANTS: Thirty-one international experts in risk-stratification and assessment of survivors of critical illness, including practitioners involved in the Society of Critical Care Medicine's Thrive Post-ICU Collaboratives, survivors of critical illness, and clinical researchers. DESIGN: Society of Critical Care Medicine consensus conference on post-intensive care syndrome prediction and assessment, held in Dallas, in May 2019. A systematic search of PubMed and the Cochrane Library was conducted in 2018 and updated in 2019 to complete an original systematic review and to identify pre-existing systematic reviews. MEETING OUTCOMES: We concluded that existing tools are insufficient to reliably predict post-intensive care syndrome. We identified factors before (e.g., frailty, preexisting functional impairments), during (e.g., duration of delirium, sepsis, acute respiratory distress syndrome), and after (e.g., early symptoms of anxiety, depression, or post-traumatic stress disorder) critical illness that can be used to identify patients at high-risk for cognitive, mental health, and physical impairments after critical illness in whom screening is recommended. We recommend serial assessments, beginning within 2-4 weeks of hospital discharge, using the following screening tools: Montreal Cognitive Assessment test; Hospital Anxiety and Depression Scale; Impact of Event Scale-Revised (post-traumatic stress disorder); 6-minute walk; and/or the EuroQol-5D-5L, a health-related quality of life measure (physical function). CONCLUSIONS: Beginning with an assessment of a patient's pre-ICU functional abilities at ICU admission, clinicians have a care coordination strategy to identify and manage impairments across the continuum. As hospital discharge approaches, clinicians should use brief, standardized assessments and compare these results to patient's pre-ICU functional abilities ("functional reconciliation"). We recommend serial assessments for post-intensive care syndrome-related problems continue within 2-4 weeks of hospital discharge, be prioritized among high-risk patients, using the identified screening tools to prompt referrals for services and/or more detailed assessments.

Long-term Renal Outcomes in Adults With Sepsis-Induced Acute Kidney Injury: A Systematic Review.

BACKGROUND: Despite advances in medical technologies and intervention occurrences, acute kidney injury (AKI) incidence continues to rise. Early interventions after sepsis are essential to prevent AKI and its long-term consequences. Acute kidney injury is the leading cause of organ failure in sepsis; therefore, more research is needed on its long-term consequences and progression to kidney injury. OBJECTIVES: The aim of this study was to review the state of the science on long-term renal outcomes after sepsis-induced AKI and long-term renal consequences. METHODS: We identified research articles from PubMed and CINAHL databases using relevant key words for sepsis-induced AKI within 5 years delimited to full-text articles in English. RESULTS: Among 1280 abstracts identified, we ultimately analyzed 12 full-text articles, identifying four common themes in the literature: (1) AKI determination criteria, (2) severity/prognosis-related factors, (3) time frame for long-term outcome measures, and (4) chronic kidney disease (CKD) and renal related exclusions. Researchers primarily used KDIGO (Kidney Disease: Improving Global Outcomes) guidelines to define AKI. All of these studies excluded patients with CKD. The range of time for long-term renal outcomes was 28 days to 3 years, with the majority being 1 year. Renal outcomes ranged from recovery to renal replacement therapy to death. CONCLUSIONS: To better understand the long-term renal outcomes after sepsis-induced AKI, more consistent measures are needed across all studies regarding the time frame and specific renal outcomes. Because all of these articles excluded patients with CKD, a gap exists on long-term renal outcome in acute on CKD.

Mast cell activation syndrome.

ABSTRACT: Mast cell activation syndrome (MCAS) is a systemic autoinflammatory disease in which mast cells behave erratically. It is unknown whether MCAS recently evolved or if it has been an unrecognized entity for years. Clinically, the patient may present in a constant to near-constant state of allergic reaction. However, the patient may also present with a variety of nonallergic symptoms. There is currently no curative treatment, and providers must prepare to be persistent in seeking symptom-management strategies. This case study describes the vast array of symptoms a typical MCAS patient may exhibit. There is a need for provider education and awareness of this disease that could affect up to 17% of the population on a spectrum from very mild to debilitating symptoms. MCAS is often either misdiagnosed or the diagnosis is greatly delayed due to a lack of provider awareness. Patients may approach primary care providers as their first line of treatment for their aberrant, mysterious symptoms, and therefore it is imperative that nurse practitioners are aware of the disease. Nurse practitioners can play a vital role in the management of MCAS using their attention to detail to recognize patterns, validate patients' experiences, and have a voice in diagnostic criteria consensus.

Survivor But Not Fully Recovered: The Lived Experience After 1 Year of Surviving Sepsis.

BACKGROUND: Hospital mortality rates related to sepsis have decreased over the last decade, increasing the number of survivors of sepsis who may experience long-term consequences. Yet, little is known about how they perceive their illness experience and its aftermath. OBJECTIVE: This study explores the experiences of sepsis survivors after 1 year of their index intensive care unit (ICU) stay. METHODS: This phenomenological study was guided by Merleau-Ponty's philosophy. Participants were adult patients admitted directly to the medical ICU with sepsis who had an ICU stay of at least 48 hours and had been discharged from their index ICU stay for at least 1 year. Participants were invited by letter to participate in face-to-face or telephone interviews and a brief survey. Interviews were audio recorded, transcribed verbatim, and verified. An interpretive group read transcripts aloud to increase rigor of identifying meaning units, existential grounds, and thematic structure. RESULTS: Eight participants were recruited over 20 months. Participants were primarily white (87.5%) females (75%) with an age range of 37 to 74 years who were interviewed between 1 and 2 years following an index sepsis ICU stay. Five major themes emerged from the transcripts: (1) how they survived, (2) blurring of time versus counting time by events, (3) helpful help versus unhelpful help, (4) powerless versus striving for control, and (5) survivor but not fully recovered. DISCUSSION: Findings reflected a long trajectory of chronic illness in which the index episode of sepsis was not necessarily what stood out as figural to participants. The meaning of participant experiences must be considered in the context of a health care system that offers little to no systematic follow-up care after sepsis and little prevention. Participants expressed a need for advocacy and follow-up support.

Enhanced Screening and Research Data Collection via Automated EHR Data Capture and Early Identification of Sepsis.

Clinical research in sepsis patients often requires gathering large amounts of longitudinal information. The electronic health record can be used to identify patients with sepsis, improve participant study recruitment, and extract data. The process of extracting data in a reliable and usable format is challenging, despite standard programming language. The aims of this project were to explore infrastructures for capturing electronic health record data and to apply criteria for identifying patients with sepsis. We conducted a prospective feasibility study to locate and capture/abstract electronic health record data for future sepsis studies. We located parameters as displayed to providers within the system and then captured data transmitted in Health Level Seven® interfaces between electronic health record systems into a prototype database. We evaluated our ability to successfully identify patients admitted with sepsis in the target intensive care unit (ICU) at two cross-sectional time points and then over a 2-month period. A majority of the selected parameters were accessible using an iterative process to locate and abstract them to the prototype database. We successfully identified patients admitted to a 20-bed ICU with sepsis using four data interfaces. Retrospectively applying similar criteria to data captured for 319 patients admitted to ICU over a 2-month period was less sensitive in identifying patients admitted directly to the ICU with sepsis. Classification into three admission categories (sepsis, no-sepsis, and other) was fair (Kappa .39) when compared with manual chart review. This project confirms reported barriers in data extraction. Data can be abstracted for future research, although more work is needed to refine and create customizable reports. We recommend that researchers engage their information technology department to electronically apply research criteria for improved research screening at the point of ICU admission. Using clinical electronic health records data to classify patients with sepsis over time is complex and challenging.

The Effect of Physical Activity on PTSD.

Although physical activity (PA) is known to reduce anxiety and depression, less is known about the effects of PA on post-traumatic stress disorder (PTSD). The author examined the state of the science regarding the effect of PA on PTSD. Three themes emerged: PA characteristics, added benefits of PA as a PTSD intervention, and theories on the method of action. Physical activity seems to be an effective adjunct therapy to reduce PTSD symptom severity. Findings are inconsistent between observational and controlled studies. More research is needed to identify the most effective type, dose, and duration of exercise. The primary author is responsible for review, synthesis, and analysis of the literature as well as preparation of the manuscript. The corresponding author is responsible for reviewing and editing the manuscript. All authors have reviewed the submitted manuscript and approve the manuscript for submission. SUMMARY STATEMENT Why is this review needed? • Post-traumatic stress disorder is a debilitating condition that is growing in prevalence and, if untreated or undertreated, can have significant impact on individuals, families, and ultimately the society at large. • Traditional treatment includes psychotherapy and pharmacotherapy; however, many who suffer from post-traumatic stress disorder have limited access to these treatment modalities. • The Institute of Medicine has called for research into cost-effective, complementary treatments to potentiate the traditional method of combined psychotherapy and pharmacotherapy. What are the key findings? • Physical activity has been shown to reduce symptoms of post-traumatic stress disorder in persons with subsyndromal symptoms and persons resistant to standard treatment. • Physical activity has also been shown to improve health conditions that may accompany PTSD (e.g., anxiety, depression, sleep disturbances, and cardiovascular disease). How should the findings be used to influence policy/practice/research/education? • Clinicians should include patient-specific exercise prescriptions in their plan of care for treating those with PTSD (e.g., walking program, aerobic activity, or yoga). • Interventions for persons with PTSD should extend beyond the relationship with the clinician, and include methods that motivate continued exercise. • Research should focus on the type and amount of activity that is most effective for treating persons with PTSD, including the length of time needed for optimal improvements to be maintained.

Unit-Level Changes in Central Line-Associated Bloodstream Infection Before and After Implementation of the Affordable Care Act and Mandatory Reporting Legislation.

BACKGROUND: Central line-associated bloodstream infection (CLABSI) prevention efforts have increased over the past decade because of implications of the Affordable Care Act and mandatory reporting laws. These legislative measures allow for reduced reimbursement to hospitals with high level of CLABSIs and other health care-associated infections. OBJECTIVE: The aim of this study was to explore the impact of legislation and mandatory reporting on CLABSI rates and reporting. METHODS: The study team performed a retrospective review of medical intensive care unit patients in January 2008, 2012, and 2015 to examine changes in CLABSI reporting by 2 methods (International Classification of Diseases [ICD] by providers and Centers for Disease Control by infection prevention [IP]), as well as changes in central line use over time. Data were summarized and compared. Percent agreement and κ statistics were calculated for ICD- and IP-coded CLABSIs. RESULTS: Among 465 intensive care unit patients, most were white (89.9%), males (52.0%), aged 58.7 ± 17.1 years. Only 3 new CLABSIs were reported during the study period: 2 by ICD and IP in 2008, 1 by ICD in 2012, and 0 by either method in 2015. The percent agreement (99.6%) and κ (0.799) represent excellent agreement. Central line usage was similar for each time period. DISCUSSION: The number of CLABSIs decreased over time; however, the findings were limited, and a larger sample over a longer period is needed to draw conclusions about the influence of legislative changes. One discrepancy was observed between the 2 reporting methods, which is consistent with other studies. More research is needed to understand the complexity of provider coding practices and changes in central line use (eg, duration, type, location) over time.

Understanding Negative Predictive Value of Diagnostic Tests Used in Clinical Practice.

Nurses review, evaluate, and use diagnostic test results on a routine basis. However, the skills necessary to evaluate a particular test using statistical outcome measures is often lacking. The purpose of this article is to examine and interpret the underlying principles for use of the statistical outcomes of diagnostic screening tests (sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values, with a discussion about use of SpPIn [Specificity, Positive test = rule in], and SnNOut [Sensitivity, Negative test = rule out]) in advanced nursing clinical practice. The authors focus on NPVs because test results with high NPV are useful to practitioners when considering unnecessary, costly, and possibly risky treatments, whether using clinical assessment tool, test, or procedure or using polymerase chain reaction analysis of DNA test results. In this article, the authors emphasize the use of NPV in treatment decisions by providing examples from critical care, neonatal, and advanced forensic nursing, which become a framework for assessing decisions in the clinical arena. This commentary stresses the importance of the NPV of tests in preventing, detecting, and ruling out disease, where PPV may not be relevant for that purpose. Negative predictive value percentages inform treatment decisions when the provider understands the biology, chemistry, and foundation for testing methods used in clinical practices. The art of diagnosis, confirmed in a test's high NPV (meaning the patient probably does not have the disease when the test is negative), reassures provider treatment stewardship to do no harm.

The Utility of the Candida Score in Patients With Sepsis.

BACKGROUND: Candida is a leading cause of infection in the intensive care unit. Colonization versus infection remains a challenge. A Candida Score (CS) of 3 or greater has been used to target antifungal therapy in surgical patients at risk of candidemia but has not been well evaluated in medical patients with sepsis. OBJECTIVES: The aim of this study was to assess utility of the CS in detecting candidemia early in patients with sepsis. METHODS: This was a secondary analysis of patients with sepsis (n = 77) who were followed up for development of new infections. Patients with known fungal infection at admission were excluded. Candida colonization was defined as Candida cultured from any baseline culture, except blood, as a part of routine clinical care. RESULTS: Candidemia was detected in 8 of 77 participants (10.4%; 4 [15.4%] with a CS ≥3 and 4 [7.8%] with a CS <3). Demographic variables (age, race, sex) were similar among those who did and did not develop candidemia. Using the recommended CS of 3 or greater, sensitivity was (4/8) 50%, specificity was (47/69) 68.1%, positive predictive value was (4/26) 15.4%, and negative predictive value was (47/51) 92.2%. Baseline colonization was significantly higher among those who developed candidemia (50% vs 11.6%; P = .02), but no significant differences were observed among CS components or total scores. CONCLUSIONS: Despite a relatively poor sensitivity, a reasonable specificity with a strong negative predictive value makes this tool a viable option for screening medically ill patients who may require antifungal agents. The CS should be evaluated in a larger, more inclusive, medical population.

Severe sepsis in older adults.

Severe sepsis may be underrecognized in older adults. Therefore, the purpose of this article is to review special considerations related to early detection of severe sepsis in older adults. Normal organ changes attributed to aging may delay early detection of sepsis at the time when interventions have the greatest potential to improve patient outcomes. Systems are reviewed for changes. For example, the cardiovascular system may have a limited or absent compensatory response to inflammation after an infectious insult, and the febrile response and recruitment of white blood cells may be blunted because of immunosenescence in aging. Three of the 4 hallmark responses (temperature, heart rate, and white blood cell count) to systemic inflammation may be diminished in older adults as compared with younger adults. It is important to consider that older adults may not always manifest the typical systemic inflammatory response syndrome. Atypical signs such as confusion, decreased appetite, and unsteady gait may occur before sepsis related organ failure. Systemic inflammatory response syndrome criteria and a comparison of organ failure criteria were reviewed. Mortality rates in sepsis and severe sepsis remain high and are often complicated by multiple organ failures. As the numbers of older adults increase, early identification and prompt treatment is crucial in improving patient outcomes.

Exaggerated plasma interleukin 6, interleukin 10, and subsequent development of health care-associated infections in patients with sepsis.

BACKGROUND: Health care-associated infections (HAIs) are the target of many well-known preventive measures in the intensive care unit (ICU); however, little is known about post-sepsis-induced immunosuppression. OBJECTIVES: This study explores the relationship between baseline plasma levels of inflammatory cytokines interleukin 6 (IL-6), IL-10, and IL-6:IL-10 and subsequent development of HAIs in patients with admitted with sepsis. METHODS: Prospective observational study was conducted among veterans admitted to the ICU with sepsis and monitored daily through ICU discharge (up to 28 days) to investigate HAI development. Baseline plasma IL-6 and IL-10 levels were measured with a multiplex bead based assay. Exaggerated systemic inflammation was defined as the fourth quartile (IL-6 and IL-10) compared with other quartiles. RESULTS: We recruited 78 patients over 18 months, primarily older (65.5 ± 12.6 years) men (94.9%) with underlying comorbidities (93.9%) and a high severity of illness (Acute Physiologic and Chronic Health Evaluation II score 20.6 ± 6.4). Seventeen patients (21.7%) developed at least 1 HAI, and candidemia was the leading infection. Patients with exaggerated baseline systemic inflammation developed a nonsignificantly higher proportion of HAI as compared with those not developing HAI (IL-6: 31.6% vs 18.6%, P = .55; IL-10: 26.3% vs 20.3%, P = .43). DISCUSSION: Patients with exaggerated systemic inflammation had a higher severity of illness, but not a statistically significant higher incidence of HAI. A larger, more adequately powered sample with serial cytokine measures is needed. Routine surveillance cultures are needed. Health care-associated infection may occur in the absence of fever, and the emerging incidence of Candida is a concern. Immune suppression after sepsis should be recognized as a risk for HAI development. Antibiotic therapy should be targeted with prompt de-escalation of empiric therapy per established guidelines to preserve normal flora.

Nursing genomics: practice implications every nurse should know.

Twenty-first century nurse clinicians, scientists, and educators must be informed of and become proficient in genetic competencies to provide the best available evidenced-based patient care. This article presents a historical context and basic applications of genetics, along with the attendant legal and ethical issues, to provide a framework for understanding genetics and the genomics applications used in clinical nursing practice. The implications of genomics are relevant to all areas of nursing practice, including risk assessment, education, clinical management, and future research.