Nurses' Attitudes, Practices, and Barriers to Assessing Symptoms of Discomfort in Mechanically Ventilated Patients: A Cross-Sectional Study.

Introduction: Critically ill patients experience various stressful symptoms of discomfort, including dyspnea, pain, and sleep disruption. Notably, ventilated patients have difficulty self-reporting discomfort symptoms. Nurses need to assess discomfort symptoms to alleviate them, but limited research exists on discomfort symptom assessment and management in critically ill patients. Objective: To identify the practices, attitudes, and barriers among nurses related to the assessment of discomfort symptoms in mechanically ventilated patients. Methods: Using a cross-sectional, descriptive study design, a web-based survey was conducted between May and June 2022 with critical care nurses sampled through Japanese academic societies and social networking services. The survey contained questions relative to the above-stated objective. Descriptive statistical analysis was performed without sample size calculation because of the descriptive and exploratory nature of this study. Results: There were 267 respondents to the questionnaire. The discomfort symptoms that nurses perceived as important to assess were pain (median 100 [interquartile range, IQR 90-100]), insomnia (99 [80-100]), and dyspnea (96.5 [75-100]). Most participants (89.8%) routinely assessed pain in mechanically ventilated patients using a scale; however, other discomfort symptoms were assessed by less than 40% (dyspnea [28.4%], fatigue [8.1%], thirst [13.1%], insomnia [37.3%], and anxiety [13.6%]). Two major barriers to assessing discomfort symptoms were lack of assessment culture within the intensive care unit and lack of knowledge of the relevant evaluation scales. Conclusions: Nurses were aware of the importance of using scales to assess the discomfort symptoms experienced by mechanically ventilated patients. However, except for pain, most nurses did not routinely use scales to assess discomfort symptoms. Barriers to routine discomfort symptom assessment included the lack of an assessment culture and the lack of knowledge of the assessment scales. Clinicians should be educated regarding the existence of validated rating scales and develop additional rating scales utilizable for minor discomforts in mechanically ventilated patients.

Nation-wide survey of oral care practice in Japanese intensive care units: A descriptive study.

Oral care for critically ill patients helps provide comfort and prevent ventilator-associated pneumonia. However, a standardized protocol for oral care in intensive care units is currently unavailable. Thus, this study aimed to determine the overall oral care practices, including those for intubated patients, in Japanese intensive care units. We also discuss the differences in oral care methods between Japanese ICUs and ICUs in other countries. This study included all Japanese intensive care units meeting the authorities' standard set criteria, with a minimum of 0.5 nurses per patient at all times and admission of adult patients requiring mechanical ventilation. An online survey was used to collect data. Survey responses were obtained from one representative nurse per intensive care unit. Frequency analysis was performed, and the percentage of each response was calculated. A total of 609 hospitals and 717 intensive care units nationwide participated; among these, responses were collected from 247 intensive care units (34.4%). Of these, 215 (87.0%) and 32 (13.0%) reported standardized and non-standardized oral care, respectively. Subsequently, the data from 215 intensive care units that provided standardized oral care were analyzed in detail. The most common frequency of practicing oral care was three times a day (68.8%). Moreover, many intensive care units provided care at unequal intervals (79.5%), mainly in the morning, daytime, and evening. Regarding oral care methods, 96 (44.7%) respondents used only a toothbrush, while 116 (54.0%) used both a toothbrush and a non-brushing method. The findings of our study reveal current oral care practices in ICUs in Japan. In particular, most ICUs provide oral care three times a day at unequal intervals, and almost all use toothbrushes as a common tool for oral care. The results suggest that some oral care practices in Japanese ICUs differ from those in ICUs in other countries.

Assessment of Dyspnea in Critically Ill Patients: A Comparative Analysis of Evaluation Scales.

Purpose This study aimed to evaluate the Respiratory Distress Observation Scale (RDOS), Intensive Care RDOS (IC-RDOS), and Mechanical Ventilation RDOS (MV-RDOS) as potential markers of dyspnea in ICU patients by describing their relationship with the Dyspnea Visual Analog Scale (D-VAS). Materials and methods A researcher and a trained nurse independently assessed ICU patients simultaneously. One researcher assessed the RDOS (IC/MV-RDOS) and the depth of sedation. An objective evaluation using the observational D-VAS was simultaneously performed by a trained nurse. Results The correlation coefficients for each scale were 0.338 for the D-VAS and RDOS, 0.239 for the IC-RDOS, and 0.237 for the MV-RDOS, indicating a low correlation. The prediction of self-reported dyspnea showed that each scale's area under the curve (AUC) as a predictor of D-VAS ≥4 was 0.79 (95% Confidence Interval [CI] 0.71-0.87) for RDOS, 0.77 (95% CI 0.68-0.84) for IC-RDOS, and 0.73 (95% CI 0.64-0.81) for MV-RDOS. Conclusions The objective rating scales RDOS, IC-RDOS, and MV-RDOS can predict subjective dyspnea to a certain extent; however, they have limitations in accurately discriminating dyspnea intensity.

Translation, Reliability, and Validity of the Japanese Clinical Reasoning Skills Self-Evaluation Scale: An Instrument Design Study.

BACKGROUND: Currently, little evidence supports the notion that improved practical skills through simulation education are reflected in actual clinical practice and ultimately lead to positive outcomes for participants. However, by clarifying the relationship between the simulation foundation and its practicality, insights can be gained to develop educational programs to improve clinical reasoning skills. However, no clear scale is currently available in Japan. AIMS: To create a valid Japanese version of the clinical reasoning skills self-evaluation scale and evaluate its reliability and validity. METHODS: This instrument design study included 580 nursing students and nurses surveyed online from February to March 2023. The clinical reasoning skills self-evaluation scale was translated into Japanese using a back-translation method, and semantic equivalence and content validity were assessed. The content validity index was assessed using a pilot test involving 26 clinical nurses, 25 nursing students, and an expert panel. Validity and reliability were tested using a convenience sample of 580 nursing students and nurses. Reliability was assessed using internal consistency and test-retest reliability. Construct validity was assessed using confirmatory factor analysis. RESULTS: Cronbach's alpha for all dimensions was >0.7, and the questionnaire showed acceptable internal consistency. Test-retest reliability was evaluated using the intraclass correlation coefficient (0.674-0.797, all dimensions); the lowest value at a 95% confidence interval was 0.504 (at least moderate reliability). CONCLUSION: Our scale has acceptable validity and reliability. It may help in clinical reasoning skill assessment for nurses and nursing students and aid in examining and supporting these skills.

Development of quality indicators for palliative care in intensive care units and pilot testing them via electronic medical record review.

BACKGROUND: Patients in intensive care units (ICUs) often require quality palliative care for relief from various types of suffering. To achieve quality palliative care, specific goals need to be identified, measured, and reported. The present study aimed to develop quality indicators (QIs) for palliative care in ICUs, based on a systematic review and modified Delphi method, and test their feasibility by reviewing electronic medical record (EMR) data. METHODS: The current study was performed in two phases: the development of QIs using the modified Delphi method, and pilot-testing the quality of palliative care in ICUs based on EMR review. The pilot test included 262 patients admitted to the general or emergency ICU at a university hospital from January 1, 2019, to June 30, 2019. RESULTS: A 28-item QI set for palliative care in ICUs was developed based on the consensus of 16 experts. The Delphi process resulted in low measurability ratings for two items: "Assessment of the patient's psychological distress" and "Assessment of the patient's spiritual and cultural practices." However, these items were determined to be important for quality care from the perspective of holistic assessment of distress and were adopted in the final version of the QI set. While the pilot test results indicated the feasibility of the developed QIs, they suggested that the frequency of care performance varied, and certain aspects of palliative care in ICUs needed to be improved, namely (1) regular pain assessment, (2) identification of the patient's advance directive and advance care planning for treatment, (3) conducting an interdisciplinary family conference on palliative care, and (4) assessment of psychological distress of family members. CONCLUSIONS: The QI set, developed using the modified Delphi method and tested using EMR data, provided a tool for assessing the quality of palliative care in ICUs. In the two ICUs considered in this study, aspects of the palliative care process with a low performance frequency were identified, and further national surveys were recommended. It is necessary to conduct ongoing surveys at more facilities to improve the quality of palliative care in ICUs.

Survey of sensory impairment in critically ill patients after intensive care unit discharge: An ambidirectional cohort study.

BACKGROUND: Sensory impairment affects the quality of life after intensive care. However, no studies have comprehensively examined sensory impairment after intensive care. OBJECTIVES: This study aimed to investigate sensory impairment in critically ill patients. METHODS: This ambidirectional cohort study was conducted in the intensive care unit (ICU) of a university hospital between April 2017 and January 2020. Patients who survived despite invasive mechanical ventilation for >48 h, with a discharge period of >6 months, participated in the study. A questionnaire was sent to consenting patients to investigate the presence or absence of sensory impairment at that time, and treatment-related data were collected from their medical records. RESULTS: Of 75 eligible patients, 62 responded to our survey. Twenty-seven (43.6%) patients had some sensory impairment. Nine (14.5%) patients had chronic pain after ICU discharge, 4 (6.5%) had chronic pain and visual impairment, 3 (4.8%) had visual impairment only, and 3 (4.8%) had chronic pain and taste impairment. The most common overlapping symptom was a combination of chronic pain. CONCLUSIONS: Critically ill patients who survived and were discharged from the ICU accounted for 43.6% of patients with complaints of sensory impairment in the chronic phase. The results of this study suggest the need for follow-up and treatment of possible sensory impairment following ICU discharge.

Survey of Guideline Compliance and Attitude Toward Symptom Management in Japanese Intensive Care Units.

Introduction: The Clinical Practice Guideline for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit (ICU) was revised in 2018 to include sleep disruption and immobility. Inadequate management of these symptoms can lead to negative consequences. A 2019 survey in Japan found that the guideline was recognized but needed to be consistently implemented. Objective: This study aimed to examine compliance with the guideline for symptom management of pain, agitation, delirium, and sleep in Japanese ICUs. Methods: This study included all ICUs in Japan and asked one representative from each unit to respond to the web survey from January 2022 to February 2022. Results: Of a potential 643 units, 125 respondents from the ICU were included in the analysis (19.4% response rate). Compared to the guideline's recommendations, (a) pain assessment was performed in 86.3% of patients who could self-report, and in 72.0% of those who could not self-report; (b) agitation and sedation assessment was performed in 99% of patients; (c) only 66.1% of nurses reported assessing sleep quality on the units, and 9.1% performed the subjective sleep quality assessment; (d) the use of the recommended risk factor of the delirium assessment tool was low (9.6%). Additionally, according to the survey respondents, contrary to the guideline, many units administered medications to prevent and treat delirium, and approximately 30% used multiple non-drug interventions. The data are expressed as numbers and percentages. Some datasets were incomplete due to missing values. Conclusion: Most units used drugs for delirium prevention and treatment, and only a few used non-drug interventions. There is a need to popularize the assessment of sleep and delirium risk factors and use non-drug interventions to promote patient-centered care in the future.

Effectiveness of Minitracheostomy After Extubation in Patients with Pneumonia at High Risk of Reintubation: A Case Series.

Introduction: Minitracheostomy involves the percutaneous insertion of a 4-mm-diameter cricothyroidotomy tube for tracheal suctioning to facilitate the clearance of airway secretions. The advantage of using the minitracheostomy is in the clearance of secretions, however data on their usefulness for respiratory failure after extubation is limited. Aim of the study: We aimed to assess the use of minitracheostomy for patients with challenging extubation caused by significant sputum. Material and Methods: We conducted a retrospective analysis of consecutive case series. We analyzed the data of 31 patients with pneumonia. After minitracheostomy, the primary endpoints of reintubation within 72 hours and clinical effects, including mortality, length of intensive care unit (ICU), or hospital stay, were assessed. The successful extubation group included patients who did not require reintubation within 72 hours. Conversely, the reintubation group consisted of patients mandating reestablishment of intubation within 72 hours. Results: Among those who underwent minitracheostomy after extubation, 22 (71%) underwent successful extubation and 9 underwent reintubation (reintubation rate: 29%). The in-hospital mortality rates after 30 days were 18.2% in the successful extubation group and 22.2% in the reintubation group. The ICU and hospital lengths of stay were 11 days (interquartile range: 8-14.3 days) and 23 days (interquartile range: 15.5-41 days), respectively, in the successful extubation group; they were 14 days (interquartile range: 11-18.5 days) and 30 days (interquartile range: 16-45.5 days), respectively, in the reintubation group. Conclusions: The prophylactic use of minitracheostomy may be an option as a means of reducing reintubation in patients with pneumonia who are at very high risk of reintubation.

Return-to-Work Prevalence Among COVID-19 Patients After Receiving Intensive Care: A Systematic Review and Meta-Analysis.

Returning to work can be a serious issue for patients who have undergone intensive care. Previous studies have reported a relatively low return-to-work prevalence among such patients. Some patients with coronavirus disease 2019 (COVID-19) experience severe pneumonia and require intensive care, including mechanical ventilation. However, little is known about the return-to-work prevalence among such patients. Therefore, we conducted a systematic review and meta-analysis of the literature describing the return-to-work prevalence among COVID-19 patients who received intensive care. The eligibility criteria were determined based on the medical condition, context, and population framework of each study, as follows: (1) full-text observational studies, (2) context: COVID-19 patients admitted to ICU, (3) condition: return-to-work prevalence after ICU discharge, and (4) population: critically ill patients who are 18 years and older. Eligible studies included randomized controlled trials (RCTs) and observational studies. Review articles, case reports, letters to the editor, and comments without data involving return-to-work prevalence were excluded. We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE, via PubMed), the Cumulated Index to Nursing and Allied Health Literature (CINAHL, via EBSCOhost), and the International Clinical Trials Registry Platform (ICTRP) databases from their inception till July 26, 2022, and updated the search on June 14, 2023. Specifically, we collected studies reporting data on the return-to-work prevalence among COVID-19 patients after receiving intensive care. Data extraction and quality assessment were performed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Prevalence Studies. Pre-developed standard forms were used for data collection, and pooled prevalence for return-to-work was calculated. Out of the 2221 available records, 42 full texts were reviewed, 20 of which were included in the qualitative synthesis. The number of return-to-work cases reported at 0-3 months, 4-6 months, and 7-12 months were three, 11, and nine, respectively. At 0-3 months, the pooled prevalence was 0.49 (three trials; n = 73; 95% CI: 0.15-0.84; I2 = 82%). At 4-6 months, the pooled prevalence was 0.57 (11 trials; n = 900; 95% CI: 0.40-0.73; I2 = 92%). Finally, at 7-12 months, the pooled prevalence was 0.64 (nine trials; n = 281; 95% CI: 0.50-0.77; I2 = 80%). However, the overall quality of the included studies was low. Based on the results, approximately one-third of COVID-19 patients did not return to work 12 months after receiving intensive care. Given the quality and limitations of the studies, a more detailed and extensive cohort study is required; also, concerned authorities should implement adequate measures in terms of providing integrated job support for this patient population.

Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023).

Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.

Second victim syndrome in intensive care unit healthcare workers: A systematic review and meta-analysis on types, prevalence, risk factors, and recovery time.

INTRODUCTION: Patient safety incidents, including medical errors and adverse events, frequently occur in intensive care units, leading to a significant psychological burden on healthcare workers. This burden results in second victim syndrome, which impacts the psychological and psychosomatic well-being of these workers. However, a systematic review focusing specifically on this condition among intensive care unit healthcare workers is lacking. Therefore, we aimed to conduct a systematic review and meta-analysis to examine the occurrence of second victim syndrome among intensive care unit healthcare workers, including the types, prevalence, risk factors, and recovery time associated with this condition. METHODS: We conducted a comprehensive search of the MEDLINE, CINAHL, PsycINFO, and Igaku Chuo Zasshi databases. The eligibility criteria encompassed retrospective, prospective, and cross-sectional studies and controlled trials, with no language restrictions. Data on the type, prevalence, risk factors, and recovery time of second victim syndrome were extracted and pooled. Prevalence estimates from the included studies were combined using a random-effects meta-analytic model. RESULTS: Of the 2,245 records retrieved, 16 potentially relevant studies were identified. Following full-text evaluation, five studies met the inclusion criteria and were included in the review. The findings revealed that 58% of intensive care unit healthcare workers experienced second victim syndrome. Frequent symptoms included guilt (12-68%), anxiety (38-63%), anger at self (25-58%), and lower self-confidence (7-58%). However, specific risk factors exclusive to intensive care unit healthcare workers were not identified in the review. Furthermore, approximately 20% of individuals took more than a year to recover or did not recover at all from the second victim syndrome. CONCLUSIONS: Thus, this condition is prevalent among intensive care unit healthcare workers and may persist for extended periods, potentially exceeding a year. The risk factors for second victim syndrome in the intensive care unit setting are unclear and require further investigation.

Early Light Sedation Increased the Duration of Mechanical Ventilation in Patients With Severe Lung Injury.

Introduction: The international guidelines recommend light sedation management for patients receiving mechanical ventilation. One of the benefits of light sedation management during mechanical ventilation is the preservation of spontaneous breathing, which leads to improved gas-exchange and patient outcomes. Conversely, recent experimental animal studies have suggested that strong spontaneous breathing effort may cause worsening of lung injury, especially in severe lung injury cases. The association between depth of sedation and patient outcomes may depend on the severity of lung injury. Objective: This study aimed to describe the patients' clinical outcomes under deep or light sedation during the first 48 h of mechanical ventilation and investigate the association of light sedation on patient outcomes for each severity of lung injury. Methods: The researchers performed a retrospective observational study at a university hospital in Japan. Patients aged ≥20 years, who received mechanical ventilation for at least 48 h were enrolled. Results: A total of 413 patient cases were analyzed. Light sedation was associated with significantly shorter 28-day ventilator-free days compared with deep sedation in patients with severe lung injury (0 [IQR 0-5] days vs. 16 [0-19] days, P = .038). In the groups of patients with moderate and mild lung injury, the sedation depth was not associated with ventilator-free days. After adjusting for the positive end-expiratory pressure and APACHE II score, it was found that light sedation decreased the number of ventilator-free days in patients with severe lung injury (-10.8 days, 95% CI -19.2 to -2.5, P = .012). Conclusion: Early light sedation for severe lung injury may be associated with fewer ventilator-free days.

Implementation of a nurse-led multidisciplinary huddle meeting for improvement of early rehabilitation in ICU: a healthcare quality improvement project.

The physical decline of critically ill patients affects their discharge from the intensive care unit (ICU) and their subsequent lives. Therefore, it is essential to actively provide rehabilitation at an early stage through multidisciplinary cooperation and protocols. This paper aims to describe the results of a project to improve the implementation rate of early rehabilitation. We established the ICU Early Rehabilitation Group, consisting of nurses, intensivists and physical therapists, and developed a protocol to perform early rehabilitation. According to this protocol, a nurse-led 'multidisciplinary rehabilitation huddle meeting' was introduced for early rehabilitation. Rehabilitation status, muscle strength and physical function were compared 9 months before and after the introduction of the huddle meeting. In addition, we assessed adverse events during rehabilitation. Since the introduction of huddle meetings, the implementation rate has been 100%. Furthermore, rehabilitation was implemented earlier and at a higher level after introducing huddle meetings. However, no significant difference was detected in muscle strength and physical function of the patients. In addition, no adverse events occurred during rehabilitation. This quality improvement project facilitated an earlier start to rehabilitation and a higher level of rehabilitation practice. Huddle meetings were smoothly introduced and settled in through multiprofessional communication. The lack of adverse events also suggested the programme's effectiveness in safely implementing this type of rehabilitation at an early and high level.

Current Practice and Barriers to the Implementation of Mobilization in ICUs in Japan: A Multicenter Prospective Cohort Study.

Background: Limited information is currently available on the barriers to implementing mobilization at the bedside for critically ill patients. Therefore, we investigated the current practice of and barriers to the implementation of mobilization in intensive care units (ICU). Methods: A multicenter prospective observational study was conducted at nine hospitals between June 2019 and December 2019. Consecutive patients admitted to the ICU for more than 48 h were enrolled. Quantitative data were analyzed descriptively, and qualitative data were analyzed thematically. Results: The 203 patients enrolled in the present study were divided into 69 elective surgical patients and 134 unplanned admission patients. The mean periods of time until the initiation of rehabilitation programs after ICU admission were 2.9 ± 7.7 and 1.7 ± 2.0 days, respectively. Median ICU mobility scales were five (Interquartile range: three and eight) and six (Interquartile range: three and nine), respectively. The most common barriers to mobilization in the ICU were circulatory instability (29.9%) and a physician's order for postoperative bed rest (23.4%) in the unplanned admission and elective surgery groups, respectively. Conclusions: Rehabilitation programs were initiated later for unplanned admission patients and were less intense than those for elective surgical patients, irrespective of the time after ICU admission.

Appetite loss and associated factors at 1 year after intensive care unit elder survivors in a secondary analysis of the SMAP-HoPe study.

Appetite loss, a common but serious issue in older patients, is an independent risk factor for sarcopenia, which is associated with high mortality. However, few studies have explored the phenomenon of appetite loss after discharge from the intensive care unit (ICU). Therefore, we aimed to describe the prevalence of appetite loss and relationship between appetite loss and depression in patients living at home 12 months after intensive care. This study involved secondary analysis of data obtained from a published ambidirectional study examining post-intensive care syndrome 12 months after discharge (SMAP-HoPe study) conducted in 12 ICUs in Japan. We included patients aged > 65 years. The Short Nutritional Assessment Questionnaire and Hospital Anxiety Depression Scale were used for the analysis. Descriptive statistics and a multilevel generalized linear model were used to clarify the relationship between appetite loss and depression. Data from 468 patients were analyzed. The prevalence of appetite loss was 25.4% (95% confidence interval [CI], 21.5-29.4). High severity of depression was associated with a high probability of appetite loss (odds ratio, 1.2; 95%CI, 1.14-1.28; p = 0.00). Poor appetite is common 12 months after intensive care and is associated with the severity of depression.

Clinical practice competencies for standard critical care nursing: consensus statement based on a systematic review and Delphi survey.

OBJECTIVES: A clear development process and scientifically validated clinical practice competencies in standard critical care nursing (SCCN) have not yet been developed in Japan. Thus, this study aimed to develop a consensus-based set of SCCN competencies to provide a framework for critical care nursing education, training and evaluation. DESIGN: Multistep, modified Delphi study (a systematic review, focus group interviews, a three-round web-based Delphi survey and an external validation process). PARTICIPANTS: A systematic review of 23 studies, focus group interviews by 12 experts, a Delphi survey by 239 critical care experts (physicians, nurses and physical therapists) and an external validation by 5 experts (physicians and nurses). RESULTS: A systematic review identified 685 unique competencies. The focus group interviews resulted in the addition of 3 performance indicator items, a synthesis of 2 subdomains and 10 elements. Of the 239 participants, 218 (91.2%), 209 (98.9%) and 201 (96.2%) responded in rounds 1, 2 and 3 of the Delphi survey, respectively. After round 3, 57 items were below the consensus level and were removed in the final round. External validation process feedback was received from experts after two revisions to ensure that the final competencies were valid, applicable, useful and clear. The final set of competencies was classified into 6 domains, 26 subdomains, 99 elements and 525 performance indicators. CONCLUSIONS: This study found a set of SCCN competencies after a multistep, modified Delphi study. The results of this study are robust, and the competency framework can be used in multiple areas to improve clinical practice, including the assessment, training and certification of standard critical care nurses.

Association of early-onset constipation and diarrhoea with patient outcomes in critically ill ventilated patients: A retrospective observational cohort study.

BACKGROUND: Constipation and diarrhoea are closely related, but few studies have examined them simultaneously. OBJECTIVES: The purpose of this study was to describe patient defecation status after intensive care unit (ICU) admission and determine the association between early-onset constipation and diarrhoea following ICU admission with outcomes for critically ill ventilated patients. METHODS: Patients ventilated for ≥48 h in an ICU were retrospectively investigated, and their defecation status was assessed during the first week after admission. Early-onset constipation and diarrhoea were defined as onset during the first week of ICU admission. The patients were divided into three groups-normal defecation, constipation, and diarrhoea-and multiple comparisons were performed using the Kruskal-Wallis test and the Mann-Whitney U test with Bonferroni adjustment. Additionally, multivariable analysis was performed for mortality and length of stay using the linear and logistic regression models. RESULTS: Of the 85 critically ill ventilated patients, 47 (55%) experienced early-onset constipation and 12 (14%) experienced early-onset diarrhoea. Patients with normal defecation and diarrhoea increased from the 4th and 5th day of ICU admission. Early-onset diarrhoea was significantly associated with the length of ICU stay (B = 7.534, 95% confidence interval: 0.116-14.951). CONCLUSIONS: Early-onset constipation and diarrhoea were common in critically ill ventilated patients, and early-onset diarrhoea was associated with the length of ICU stay.

Use of Automated Infrared Pupillometry to Predict Delirium in the Intensive Care Unit: A Prospective Observational Study.

Introduction: Delirium is an acute state of brain dysfunction prevalent among critically ill patients. Disturbances in the sympathetic neurons, including cholinergic neurons, have been reported to cause delirium by upsetting the balance of neurotransmitter synthesis, release, and inactivation. The cholinergic system mediates pupillary constriction as a response to light stimulation, and this reflex can be measured using automated infrared pupillometry (AIP). The relationship between delirium and AIP parameters has been examined. The Confusion Assessment Method for the Intensive Care Unit (CAM ICU) and the Intensive Care Unit Delirium Screening Checklist (ICDSC) are used for assessing delirium. However, that between the ICDSC score and AIP parameters remains unclear. Objective: To examine the relationship between AIP parameters and the various categories of delirium as defined by the ICDSC score (delirium, subsyndromal delirium, no delirium). Methods: This prospective observational study included patients aged ≥18 years admitted to the intensive care unit (ICU) from May 2018 to September 2018. ICU patients were classified into delirium, subsyndromal delirium, and no delirium groups according to the ICDSC score during ICU stay. The pupillary light reflex was assessed in both eyes immediately after admission using AIP with a portable infrared pupillometer. Logistic regression analyses were used to estimate the odds ratio to examine the relationship between the severity of delirium as assessed by the ICDSC score and the AIP parameters. Results: In total 133 patients were included in the study. Based on the ICDSC scores, 41.4% of patients had no delirium, 40.6% had subsyndromal delirium, and 18% had delirium. Dilation velocity (DV) measured by AIP was significantly different among the delirium, subsyndromal delirium, and no delirium groups. Post-hoc comparisons showed that DV was significantly slower in the delirium group than in the no delirium group but was not significantly different between the subsyndromal delirium and no delirium groups. After adjusting for patients' sex and age at enrollment, DV was shown to be independently associated with delirium. Conclusion: This study suggests that the use of AIP at ICU admission may improve the identification of patients at a high risk of developing delirium.

The efficacy and safety of nurse-initiated sedation management in an intensive care unit: A two-phase prospective study in Japan.

AIM: This study aimed to evaluate whether nurse-initiated sedation management could provide more appropriate sedation compared to usual care in a Japanese intensive care unit (ICU). METHODS: We conducted a single-center, prospective observational study before and after implementing nurse-initiated sedation using instruction sheets. Patients who had been admitted to a general adult ICU were enrolled. Before our ICU started nurse-initiated sedation (pre-implementation care), adjustment of sedatives and analgesics was performed only by a physician's written or verbal order; however, after implementing nurse-initiated sedation, nurses titrated drugs using instruction sheets. The primary outcome was the efficacy of nurse-initiated sedation, evaluated by the proportion achieving the target Richmond Agitation-Sedation Scale (RASS) score. The analgesic status evaluated by Critical-Care Pain Observation Tool (CPOT), days of delirium, ventilator days, ICU mortality and hospital mortality were also evaluated. RESULTS: The study examined 30 patients in the pre-implementation care phase and 30 patients in the nurse-initiated sedation phase. The proportions achieving the target RASS were 68% in the nurse-initiated sedation group and 42% in the pre-implementation care group (mean difference, 25%; 95% confidence interval, 13.4%-37.5%; P <.001). Almost all measured CPOT were within the range of 0-3 during both phases. Days of delirium, ventilator days, ICU survival, and hospital survival did not differ significantly between the two groups. CONCLUSIONS: Nurse-initiated sedation management achieved a significantly higher degree of target sedation status and was incorporated as part of the care in our ICU. It is a safe approach in countries, such as Japan, where sedation protocols are not widely used.

Employment status and its associated factors for patients 12 months after intensive care: Secondary analysis of the SMAP-HoPe study.

BACKGROUND: Returning to work is a serious issue that affects patients who are discharged from the intensive care unit (ICU). This study aimed to clarify the employment status and the perceived household financial status of ICU patients 12 months following ICU discharge. Additionally, we evaluated whether there exists an association between depressive symptoms and subsequent unemployment status. METHODS: This study was a subgroup analysis of the published Survey of Multicenter Assessment with Postal questionnaire for Post-Intensive Care Syndrome for Home Living Patients (the SMAP-HoPe study) in Japan. Eligible patients were those who were employed before ICU admission, stayed in the ICU for at least three nights between October 2019 and July 2020, and lived at home for 12 months after discharge. We assessed the employment status, subjective cognitive functions, household financial status, Hospital Anxiety and Depression Scale, and EuroQOL-5 dimensions of physical function at 12 months following intensive care. RESULTS: This study included 328 patients, with a median age of 64 (interquartile range [IQR], 52-72) years. Of these, 79 (24%) were unemployed 12 months after ICU discharge. The number of patients who reported worsened financial status was significantly higher in the unemployed group (p<0.01) than in the employed group. Multivariable analysis showed that higher age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.03-1.08]) and greater severity of depressive symptoms (OR, 1.13 [95% CI, 1.05-1.23]) were independent factors for unemployment status at 12 months after ICU discharge. CONCLUSIONS: We found that 24.1% of our patients who had been employed prior to ICU admission were subsequently unemployed following ICU discharge and that depressive symptoms were associated with unemployment status. The government and the local municipalities should provide medical and financial support to such patients. Additionally, community and workplace support for such patients are warranted.