Stethoscope barriers narrative review; It's time for a strategy unfriendly to multi-drug resistant organisms (MDROs).

The current standard of stethoscope hygiene doesn't eliminate the transmission of harmful pathogens, including multi-drug resistant organisms (MDROs). In the era of the increasing prevalence of MDRO infections, the use of new systems providing touch free barriers may improve patient safety versus traditional stethoscope cleaning practices with chemical agents. Our purpose was to provide a narrative literature review regarding barriers as an improvement over the current standard of care for stethoscope hygiene. Searching PubMed, articles were identified if they were in English and published after 1990, using the search term "stethoscope barrier", or if they were from a previously published stethoscope hygiene article using "author's name + stethoscope". Included articles evaluated or discussed stethoscope barriers. Of 28 manuscripts identified, 15 met the inclusion criteria. Barriers were considered superior to alternatives if they were single use, disposable, applied in a touch free fashion, were impervious to pathogens, provided an aseptic patient contact, and were acoustically invisible. Use of a practitioner's personal stethoscope with a disposable diaphragm barrier should be recommended as a new standard of care as this represents an improvement in patient safety and patient experience when compared to the disposable stethoscope or isopropyl alcohol stethoscope diaphragm cleaning.

Enhancing prone positioning and skin damage prevention education: A randomized controlled non-inferiority trial comparing a digital education hub (PRONEtect) and a traditional lecture on final-year nursing participants' confidence and knowledge.

INTRODUCTION: The incidence of pressure ulcers remains high in patients with moderate to severe acute respiratory distress syndrome, ventilated in the prone position. A digital platform, dedicated to prone positioning and skin/tissue damage education was developed. OBJECTIVE: To evaluate the impact of the PRONEtect Education Hub versus a traditional lecture on final-year nursing students' confidence levels and knowledge in a non-inferiority study. DESIGN: A multicenter, non-blinded, parallel-group, non-inferiority study with equal randomization (1:1 allocation) was conducted at two nursing schools in Belgium. CLINICALTRIALS: gov (NCT05575869). METHODS: Following baseline assessments, the control group received a 1-h classroom lecture, and the experimental group gained access to the PRONEtect website. Three weeks later, participants completed the knowledge, confidence, and visual knowledge assessment. RESULTS: At baseline, 67 of the 80 participants completed the assessments and post-intervention, 28 and 27 participants respectively completed the confidence, knowledge, and visual knowledge assessments (dropout rate of 66.25%). Confidence levels: a mean ratio of relative change from baseline = 0.96 (Control (C)/Experimental (E)); 97.5% confidence interval (CI): 0.74 to 1.26; p = 0.74. Knowledge assessment: a mean difference in change from baseline = 1.58 (C-E); 97.5% CI: -0.58 to 3.75; p = 0.1. Although confidence and knowledge scores increased in both groups, the study cannot conclude non-inferiority. CONCLUSIONS: The trade-off between the inability to conclude efficacy of the impact of the website and the benefit of having an accessible educational platform on prone positioning and skin damage prevention makes the PRONEtect Education Hub an acceptable adjunct to traditional lecturing.

Development of prone positioning and skin damage prevention digital education: the PRONEtect project.

OBJECTIVE: The incidence of skin/tissue damage, such as pressure ulcers, remains high in mechanically ventilated patients in the prone position. According to guidelines, critically ill patients with acute respiratory distress syndrome (ARDS) should be prone for at least 12-16 hours to improve oxygenation and decrease mortality. Therefore, educating clinicians on how to reposition and manage the patient safely in a prone position plays a vital role in preventing adverse events. This project aimed to develop accessible online educational content to assist clinicians in safely executing the prone manoeuvre and minimise skin/tissue damage. METHOD: The development of the educational content was based on: a gap analysis and comprehensive review of available educational resources; evidence-based scientific literature; advice from international experts; and a qualitative study exploring the learning needs of 20 clinicians in Belgium and Sweden between February-August 2022. RESULTS: Volunteer clinicians assisted with the creation of eight simulation videos which were professionally filmed and edited. The interactive videos included the supine-to-prone and prone-to-supine manoeuvres, endotracheal and nasogastric tube securement, eye care, stoma care, protecting high-risk areas from pressure damage, and incontinence-associated dermatitis prevention. A prone positioning protocol, a checklist summarising the key aspects of the protocol, and teaching aids (slide deck for didactic lecturing) were developed and validated by a review of the relevant evidence-based literature and the international expert panel. A website was designed to host the content, with free user access, at www.pronetection.com. CONCLUSION: Education is one strategy towards prevention of complications of prone positioning. Accessible education could assist clinicians unfamiliar with prone positioning or current clinicians requiring refresher training to safely manage patients in this position.

Work climate in emergency health services during COVID-19 pandemic-An international multicenter study.

Introduction: A good working climate increases the chances of adequate care. The employees of Emergency in Hospitals are particularly exposed to work-related stress. Support from management is very important in order to avoid stressful situations and conflicts that are not conducive to good work organization. The aim of the study was to assess the work climate of Emergency Health Services during COVID-19 Pandemic using the Abridged Version of the Work Climate Scale in Emergency Health Services. Design: A prospective descriptive international study was conducted. Methods: The 24-item Abridged Version of the Work Climate Scale in Emergency Health Services was used for the study. The questionnaire was posted on the internet portal of scientific societies. In the study participated 217 women (74.5%) and 74 men (25.4%). The age of the respondents ranged from 23 to 60 years (SD = 8.62). Among the re-spondents, the largest group were Emergency technicians (85.57%), followed by nurses (9.62%), doctors (2.75%) and Service assistants (2.06%). The study was conducted in 14 countries. Results: The study of the climate at work shows that countries have different priorities at work, but not all of them. By answering the research questions one by one, we can say that the average climate score at work was 33.41 min 27.0 and max 36.0 (SD = 1.52). Conclusion: The working climate depends on many factors such as interpersonal relationships, remuneration or the will to achieve the same selector. In the absence of any of the elements, a proper working climate is not possible.

Clinical Nurse Specialist: A Critical Member of the ICU Team.

OBJECTIVES: To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided. DATA SOURCES: Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical-Care Nurses, and National Association of Clinical Nurse Specialists. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Not applicable. CONCLUSIONS: The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

Skin damage prevention in the prone ventilated critically ill patient: A comprehensive review and gap analysis (PRONEtect study).

BACKGROUND: Ventilating critically ill patients with acute respiratory distress syndrome in the prone position is a life-saving strategy, but it is associated with adverse consequences such as skin damage. AIM: To identify, review and evaluate international proning and skin care guidelines and make an inventory of commonly used equipment and training resources. DESIGN: A gap analysis methodology was applied. METHODS: 1) Comprehensive search and evaluation of proning and skin care guidelines, 2) extensive search and listing equipment and educational resources, and 3) international consultation with 11 experts (8 countries). DATA SOURCES: A variety of sources researched through July 2021 were used to identify relevant literature: (1) scientific literature databases and clinical trials registries, (2) intensive care and wound care associations, (3) healthcare organisations, (4) guideline development organisations, and (5) the Google search engine. Eleven international experts reviewed the literature and provided insights in two, 2-h online sessions. FINDINGS: The search yielded 24 guidelines. One clinical practice guideline had high methodological quality. Twenty-five devices/equipment and sixteen teaching materials were identified and discussed with the expert panel. The gap analysis identified a lack of concise, accessible, evidence-based guidelines and educational materials of short duration. CONCLUSION: This analysis forms the basis for designing a competency-based education and training intervention for an interdisciplinary team caring for the skin of critically ill patients in the prone position. IMPACT: The results can assist the multidisciplinary team to review their current protocol for prone positioning. This is a first step in developing a training package for clinicians.

Clinical Nurse Specialist: A Critical Member of the ICU Team.

OBJECTIVES: To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided. DATA SOURCES: Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical Care Nurses, and National Association of Clinical Nurse Specialists. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Not applicable. CONCLUSIONS: The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

Clinical Nurse Specialist: A Critical Member of the ICU Team.

OBJECTIVES: To describe the role of the clinical nurse specialist, an advanced practice registered nurse in the intensive care setting. The value and impact of the clinical nurse specialist role as a member of the ICU is presented along with a review of clinical nurse specialist education, licensure, and certification requirements as well as a description of the clinical nurse specialist role, scope of practice, and competencies. In addition, a selected review of clinical nurse specialist-led quality improvement and research that resulted in improved patient outcomes is provided. DATA SOURCES: Review of published medical and nursing literature and expert opinion guidance from a collaborative effort between the Society of Critical Care Medicine, American Association of Critical Care Nurses, and National Association of Clinical Nurse Specialists. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Not applicable. CONCLUSIONS: The utilization of a clinical nurse specialist, an advanced practice role, in the ICU is a unique and valuable approach for organizations who strive to move evidence into sustainable practice and drive quality through an interprofessional approach. The valuable contributions made by the clinical nurse specialist efficiently and effectively meet the needs of patients, clinicians, and organizations while improving patient outcomes and optimizing cost avoidance strategies, which further lower economic demands on the healthcare system.

Awake Proning as an Adjunctive Therapy for Refractory Hypoxemia in Non-Intubated Patients with COVID-19 Acute Respiratory Failure: Guidance from an International Group of Healthcare Workers.

Non-intubated patients with acute respiratory failure due to COVID-19 could benefit from awake proning. Awake proning is an attractive intervention in settings with limited resources, as it comes with no additional costs. However, awake proning remains poorly used probably because of unfamiliarity and uncertainties regarding potential benefits and practical application. To summarize evidence for benefit and to develop a set of pragmatic recommendations for awake proning in patients with COVID-19 pneumonia, focusing on settings where resources are limited, international healthcare professionals from high and low- and middle-income countries (LMICs) with known expertise in awake proning were invited to contribute expert advice. A growing number of observational studies describe the effects of awake proning in patients with COVID-19 pneumonia in whom hypoxemia is refractory to simple measures of supplementary oxygen. Awake proning improves oxygenation in most patients, usually within minutes, and reduces dyspnea and work of breathing. The effects are maintained for up to 1 hour after turning back to supine, and mostly disappear after 6-12 hours. In available studies, awake proning was not associated with a reduction in the rate of intubation for invasive ventilation. Awake proning comes with little complications if properly implemented and monitored. Pragmatic recommendations including indications and contraindications were formulated and adjusted for resource-limited settings. Awake proning, an adjunctive treatment for hypoxemia refractory to supplemental oxygen, seems safe in non-intubated patients with COVID-19 acute respiratory failure. We provide pragmatic recommendations including indications and contraindications for the use of awake proning in LMICs.

Improving the care and health of populations through optimal use of clinical nurse specialists.

Patients with complex and chronic illnesses and those who have significant needs related to care coordination and transitions of care are dependent on access to healthcare providers who are skilled at meeting the distinct needs of these populations and are current in the latest evidence-based practices and guidelines. Clinical nurse specialists (CNSs) are uniquely qualified to care for patients with complex illnesses as well as having the skills to optimize care for entire populations with complex needs. The absence of consistent legislative advanced practice registered nurse recognition of CNSs prevents health care systems from optimal use of this advanced practice registered nurse role to improve and provide safe and quality care for these patients. Additional barriers in optimal utilization of CNSs include lack of consistency: in title protection and licensing from state to state; ensuring patient access through identification and tracking of CNS numbers across the United States in order to determine workforce and educational program requirements; and ensuring appropriate reimbursement for care provided by CNSs. Therefore, it is the position of the American Academy of Nursing that addressing public and private sector regulatory, legislative, and policy concerns related to CNSs is essential to achieving optimal population health outcomes across the nation.

Changing the Perceptions of a Culture of Safety for the Patient and the Caregiver: Integrating Improvement Initiatives to Create Sustainable Change.

Evidence indicates that chances for a successful patient mobility program, prevention of pressure injury and falls, and safe patient handling are enhanced when an organization possesses an appropriate culture for safety. Frequently, these improvement initiatives are managed within silos often creating a solution for one and a problem for the others. A model of prevention integrating early patient mobility, preventing pressure injuries and falls while ensuring caregiver safety, is introduced. The journey begins by understanding why early mobility and safe patient handling are critical to improving overall patient outcomes. Measuring current culture and understanding the gaps in practice as well as strategies for overcoming some of the major challenges for success in each of these areas will result in sustainable change.

What is an intensive care unit? A report of the task force of the World Federation of Societies of Intensive and Critical Care Medicine.

Since their widespread introduction more than half a century ago, intensive care units (ICUs) have become an integral part of the health care system. Although most ICUs are found in high-income countries, they are increasingly a feature of health care systems in low- and middle-income countries. The World Federation of Societies of Intensive and Critical Care Medicine convened a task force whose objective was to answer the question "What is an ICU?" in an internationally meaningful manner and to develop a system for stratifying ICUs on the basis of the intensity of the care they provide. We undertook a scoping review of the peer-reviewed and gray literature to assemble existing models for ICU stratification. Based on these and on discussions among task force members by teleconference and 2 face-to-face meetings, we present a proposed definition and classification of ICUs. An ICU is an organized system for the provision of care to critically ill patients that provides intensive and specialized medical and nursing care, an enhanced capacity for monitoring, and multiple modalities of physiologic organ support to sustain life during a period of life-threatening organ system insufficiency. Although an ICU is based in a defined geographic area of a hospital, its activities often extend beyond the walls of the physical space to include the emergency department, hospital ward, and follow-up clinic. A level 1 ICU is capable of providing oxygen, noninvasive monitoring, and more intensive nursing care than on a ward, whereas a level 2 ICU can provide invasive monitoring and basic life support for a short period. A level 3 ICU provides a full spectrum of monitoring and life support technologies, serves as a regional resource for the care of critically ill patients, and may play an active role in developing the specialty of intensive care through research and education. A formal definition and descriptive framework for ICUs can inform health care decision-makers in planning and measuring capacity and provide clinicians and patients with a benchmark to evaluate the level of resources available for clinical care.

Interventional patient hygiene: discussion of the issues and a proposed model for implementation of the nursing care basics.

More than 140 years ago, Florence Nightingale wrote "It may seem a strange principal to enunciate as the very first requirement in a Hospital that it should do the sick no harm." Data suggests that 63% of all preventable errors are related to clinical problems that are within nursing's independent scope of practice. Many of these fall in the category of "interventional hygiene" activities and include prevention of skin injury, post-operative respiratory complications and failure to rescue. As nurses we are called upon to assure higher levels of safety and quality for our patients by our governments, professional organisations and hospital administrations. It is essential that we implement evidence based nursing care strategies to reduce avoidable errors in care so that clinical outcomes improve. The author of this paper, who coined the team "interventional patient hygiene", discusses the science related to many of these care issues and proposes an Interventional Care Model for use by nurses in redesigning how we approach nurse sensitive care practices in the future. Additionally, a change framework called "Sustaining Nursing Clinical Practice" is described to ensure reintroduction and valuing of evidence basic nursing care in conjunction with the right resources and systems to sustain the new practice.

Understanding critically ill patients hemodynamic response to mobilization: using the evidence to make it safe and feasible.

In today's critical care environment, we face a difficult but essential task. We must provide comprehensive, compassionate, complex, technological care without causing harm to our patients. To foster a patient-safe environment, we must examine care practices and processes to reduce the chance of error. Successful early mobilization of critically ill patients can reduce several complications including atelectasis and ventilator-associated pneumonia and shorten ventilator time along with cognitive and functional limitations that linger 1 to 5 years after discharge from the intensive care unit. A long-standing challenge to successful mobilization of critically ill patients is the safety concern of hemodynamic instability. An in-depth exploration of what happens to a critically ill patient physiology during mobilization was done to foster a better understanding of strategies that promote adaptation. The article examines the evidence supporting the need to assess readiness for mobilization to reduce the risk of adverse events. Evidence-based tools and techniques to help clinicians prevent hemodynamic instability before, during, and after in-bed or out-of-bed mobilization are discussed. With safety serving as the overriding goal, we can overcome the barriers and succeed in creating and sustaining a culture of early progressive mobility programs within the intensive care unit.

Integrating a multidisciplinary mobility programme into intensive care practice (IMMPTP): a multicentre collaborative.

BACKGROUND: ICU immobility can contribute to physical deconditioning, increased ICU and hospital length of stay and complications post discharge. Despite evidence of the beneficial outcomes of early mobility, many ICUs and providers lack necessary processes and resources to effectively integrate early mobility into their daily practice. OBJECTIVE: To create a progressive mobility initiative that will help ICU teams to address key cultural, process and resource opportunities in order to integrate early mobility into daily care practices. METHODS: An initiative to integrate the latest evidence on mobility practice into current ICU culture in 13 ICUs in eight hospitals within the US was launched. A user-friendly, physiologically grounded evidence-based mobility continuum was designed and implemented. Appropriate education and targeted messaging was used to engage stakeholders. To support and sustain the implementation process, mechanisms including coaching calls and various change interventions were offered to modify staffs' practice behaviour. Qualitative data was collected at two time points to assess cultural and process issues around mobility and provided feedback to the stakeholders to support change. Quantitative date on ventilator days and timing of physical therapy consultation was measured. RESULTS: Qualitative reports of the mobility programme participants suggest that the methods used in the collaborative approach improved both the culture and team focus on the process of mobility. There were no significant differences demonstrated in any of the mobility intervention group measurement however, a reduction in ventilator days (3.0days pre vs. 2.1 days post) approached significance (p=0.06). CONCLUSION: This multi-centre, ICU collaborative has shown that improvements in team culture, communication and resources can improve adoption of early mobility in ICU patients.