[Therapeutic restraint management in Intensive Care Units: Phenomenological approach to nursing reality]. / Manejo de la inmovilización terapéutica en Unidades de Cuidados Críticos: aproximación fenomenológica a la realidad enfermera.

AIMS: To identify nursing experience on physical restraint management in Critical Care Units. To analyse similarities and differences in nursing experience on physical restraint management according to the clinical context that they are involved in. METHOD: A multicentre phenomenological study was carried out including 14 Critical Care Units in Madrid, classified according to physical restraint use: Common/systematic use, lacking/personalised use, and mixed use. Five focus groups (23 participants were selected following purposeful sampling) were convened, concluding in data saturation. Data analysis was focused on thematic content analysis following Colaizzi's method. FINDINGS: Six main themes: Physical restraint meaning in Critical Care Units, safety (self-retreat vital devices), contribution factors, feelings, alternatives, and pending issues. Although some themes are common to the 3 Critical Care Unit types, discourse differences are found as regards to indication, feelings, systematic use of pain and sedation measurement tools. CONCLUSIONS: In order to achieve real physical restraint reduction in Critical Care Units, it is necessary to have a deep understanding of restraints use in the specific clinical context. As self-retreat vital devices emerge as central concept, some interventions proposed in other settings could not be effective, requiring alternatives for critical care patients. Discourse variations laid out in the different Critical Care Unit types could highlight key items that determine the use and different attitudes towards physical restraint.

Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients.

OBJECTIVE: To assess the psychometric properties of the behavioral indicators of pain scale (ESCID) when applied to a wide range of medical and surgical critical patients. DESIGN: A multicentre, prospective observational study was designed to validate a scale measuring instrument. SETTING: Twenty Intensive Care Units of 14 hospitals belonging to the Spanish National Health System. PARTICIPANTS: A total of 286 mechanically ventilated, unable to self-report critically ill medical and surgical adult patients. PROCEDURE: Pain levels were measured by two independent evaluators simultaneously, using two scales: ESCID and the behavioral pain scale (BPS). Pain was observed before, during, and after two painful procedures (turning, tracheal suctioning) and one non-painful procedure. MAIN VARIABLES: ESCID reliability was measured on the basis of internal consistency using the Cronbach-α coefficient. Inter-rater and intra-rater agreement were measured. The Spearman correlation coefficient was used to assess the correlation between ESCID and BPS. RESULTS: A total of 4386 observations were made in 286 patients (62% medical and 38% surgical). High correlation was found between ESCID and BPS (r=0.94-0.99; p<0.001), together with high intra-rater and inter-rater concordance. ESCID was internally reliable, with a Cronbach-α value of 0.85 (95%CI 0.81-0.88). Cronbach-α coefficients for ESCID domains were high: facial expression 0.87 (95%CI 0.84-0.89), calmness 0.84 (95%CI 0.81-0.87), muscle tone 0.80 (95%CI 0.75-0.84), compliance with mechanical ventilation 0.70 (95%CI 0.63-0.75) and consolability 0.85 (95%CI 0.81-0.88). CONCLUSION: ESCID is valid and reliable for measuring pain in mechanically ventilated unable to self-report medical and surgical critical care patients. CLINICALTRIALS.GOV: NCT01744717.

The impact and recovery of asteroid 2008 TC(3).

In the absence of a firm link between individual meteorites and their asteroidal parent bodies, asteroids are typically characterized only by their light reflection properties, and grouped accordingly into classes. On 6 October 2008, a small asteroid was discovered with a flat reflectance spectrum in the 554-995 nm wavelength range, and designated 2008 TC(3) (refs 4-6). It subsequently hit the Earth. Because it exploded at 37 km altitude, no macroscopic fragments were expected to survive. Here we report that a dedicated search along the approach trajectory recovered 47 meteorites, fragments of a single body named Almahata Sitta, with a total mass of 3.95 kg. Analysis of one of these meteorites shows it to be an achondrite, a polymict ureilite, anomalous in its class: ultra-fine-grained and porous, with large carbonaceous grains. The combined asteroid and meteorite reflectance spectra identify the asteroid as F class, now firmly linked to dark carbon-rich anomalous ureilites, a material so fragile it was not previously represented in meteorite collections.

Non-pharmacological interventions to reduce physical restraints in critical care units.

Physical restraint use in critical care units is a frequent low-value care practice influenced by numerous factors creating a local culture. The translation of evidence-based recommendations into clinical practice is scarce so, the analysis of interventions to de-adopt this practice is needed. This update aims to describe and identify nonpharmacological interventions that contribute to minimising the use of physical restraints in adult critically ill patients. Interventions are classified into two groups: those that include education alone and those that combine training with one or more components (multicomponent interventions). These components include less restrictive restraint alternatives, use of physical and cognitive stimulation, decision support tools, institutional multidisciplinary committees, and team involvement. The heterogeneity in the design of the programmes and the low quality of the evidence of the interventions do not allow us to establish recommendations on their effectiveness. However, multicomponent interventions including training, physical and cognitive stimulation of the patient and a culture change of professionals and the organisations towards making restraints visible might be the most effective. The implementation of these programmes should underpin on a prior analysis of each local context to design the most effective-tailored combination of interventions to help reduce or eliminate them from clinical practice.

Validación de un cuestionario de conocimientos adquiridos por los pacientes tras un taller educativo de artroplastia de rodilla.

INTRODUCTION: Total knee arthroplasty (TKA) is a surgery that aims to restore function and relieve pain in advanced osteoarthritis. The Educational Workshop (EW) for TKA is given to patients in the pre-surgery period to inform them and facilitating their participation in their health process (empowerment). The aim of this study was developing and validating a self-administered questionnaire to evaluate the acquired knowledge after the EW by the patients who will undergo the TKA procedure. MATERIAL AND METHODS: It was a longitudinal and prospective observational study with a sample of TKA candidate patients. The phases for the construction and validation of this ad hoc questionnaire were: Phase 1: A panel of experts who agreed on a final questionnaire of 20 items; Phase 2: Pilot test administered to 47 patients; Phase 3: Final test of 11 items administered to 50 patients, before and after the EW; Phase 4: Re-test, after the EW and 2 weeks after, administered to 58 patients. RESULTS: One hundred and fifty five patients were included. The Cronbach's alpha coefficient for the item's internal consistency of the final questionnaire, 11 items, was 0.78. To reach the criterion validity, in pre-EW the mean number of hits was: 4.92 (SD=1.78) and in post-EW 10.68 (SD=0.55), a difference that had a statistical significance p<.0001, with no overlap in the 95% CI of the mean: 4.46-5.38/10.54-10.82. The test for stability and reliability, re-test, obtained a mean of right answers 10.87 (SD=0.33) and for the re-test of 10.70 (SD=0.59). The correlation of the interclass coefficient for the re-test was 0.99, which corresponds almost to a maximum concordance. CONCLUSIONS: The questionnaire developed in this study is a reliable and easy tool to evaluate the acquired knowledge in the EW for patients who will be TKA operated.

The use of mechanical restraint in critical care units: Characterisation, application standards and related factors. Results of a multicentre study.

OBJECTIVES: To describe and characterise the use of mechanical restraint (MR) in critical care units (CCU) in terms of frequency and quality of application and to study its relationship with pain/agitation-sedation/delirium, nurse:patient ratio and institutional involvement. METHOD: Multicentre observational study conducted in 17 CCUs between February and May 2016. The observation time per CCU was 96 h. The main variables were the prevalence of restraint, the degree of adherence to MR recommendations, pain/agitation-sedation/delirium monitoring and institutional involvement (protocols and training of professionals). RESULTS: A total of 1070 patients were included. The overall prevalence of restraint was 19.11%, in patients with endotracheal tube (ETT) 42.10% and in patients without ETT or artificial airway it was 13.92%. Adherence rates between 0% and 40% were obtained for recommendations related to non-pharmacological management and between 0% and 100% for those related to monitoring of ethical-legal aspects. The lower prevalence of restraint was correlated with adequate pain monitoring in non-communicative patients (P < .001) and with the provision of training for professionals (P = .020). An inverse correlation was found between the quality of the use of MR and its prevalence, both in the general group of patients admitted to CCU (r = -.431) and in the subgroup of patients with ETT (r = -.521). CONCLUSIONS: Restraint is especially frequently used in patients with ETT/artificial airway, but is also used in other patients who may not meet the use profile. There is wide room for improvement in non-pharmacological alternatives to the use of MC, ethical and legal vigilance, and institutional involvement. Better interpretation of patient behaviour with validated tools may help limit use of MR.

Assessment of analgesia, sedation, physical restraint and delirium in patients admitted to Spanish intensive care units. Proyecto ASCyD. / Valoración de la analgesia, sedación, contenciones y delirio en los pacientes ingresados en unidades de cuidados intensivos españolas. Proyecto ASCyD.

AIMS: Main aim: To determine the Spanish intensive care units (ICU) that assess and record pain levels, sedation/agitation, delirium and the use of physical restraint (PR) as standard practice. Secondary aims: To determine the use of validated assessment tools and to explore patients' levels of pain and sedation/agitation, the prevalence of delirium, and the use of PR. METHOD: An observational, descriptive, cross-sectional, prospective and multicentre study using an ad hoc survey with online access that consisted of 2 blocks. Block I: with questions on the unit's characteristics and routine practice; Block II: aspects of direct care and direct assessments of patients admitted to participating units. RESULTS: One hundred and fifty-eight units and 1574 patients participated. The pain of communicative patients (CP) was assessed and recorded as standard in 109 units (69%), the pain of non-communicative patients (NCP) in 84 (53%), sedation/agitation in 111 (70%), and delirium in 39 units (25%). There was recorded use of PR in 39 units (25%). Validated scales were used to assess the pain of CP in 139 units (88%), of NCP in 102 (65%), sedation/agitation in 145 (92%), delirium in 53 units (34%). In 33 units (21%) pain, sedation/agitation and delirium of PC and NPC was assessed, and in 8 of these units there was a specific PR protocol and register. Among the patients who could be assessed, an absence of pain was reported in 57%, moderate pain in 27%; 48% were calm and collaborative, and 10% agitated; 21% had PR, and 12.6% of the patients had delirium. CONCLUSIONS: The assessment of pain, sedation and delirium is demonstrated, and low percentages of agitation and delirium achieved. We observed a high percentage of patients with pain, and moderate use of PC. We should generalise the use of protocols to assess, prevent and treat pain and delirium by appropriately managing analgesia, sedation, and individual and well-considered use of PC. (ClinicalTrials.gov Identifier: NCT03773874).

Physical restraint in critical care units from the experience of doctors and nursing assistants: In search of an interdisciplinary interpretation. / La contención mecánica en unidades de cuidados críticos desde la experiencia de los médicos y técnicos en cuidados auxiliares de enfermería: buscando una lectura interdisciplinar.

OBJECTIVES: The study aim was to explore the experience of doctors and nursing assistants in the management of physical restraint (PR) in critical care units. METHOD: A multicentre phenomenological study that included 14 critical care units (CCU) in Madrid (Spain). The CCU were stratified according to their use of physical restraint: "frequently used" versus "seldom used". Three focus groups were formed: the first comprised nursing assistants from CCUs that frequently used physical restraint, the second comprised nursing assistants from CCUs that seldom used physical constraint, and the final group comprised doctors from both CCU subtypes. Sampling method: purposive. DATA ANALYSIS: thematic content analysis. Data saturation was achieved. RESULTS: Four principle themes emerged: 1) concept of safety and risk (patient safety versus the safety of the professional), 2) types of restraint, 3) professional responsibilities (prescription, recording, and professional roles) and 4) "zero restraint" paradigm. The conceptualisation regarding the use of physical contentions shows differences in some of the principal themes, depending on the type of CCU, in terms of policies, use and management of physical constraint (frequently used versus seldom used). CONCLUSIONS: The real reduction in the use of physical restraint in CCU must be based on one crucial point: acceptance of the complexity of the phenomenon. The use of physical restraint observed in the different CCU is influenced by individual, group and organisational factors. These factors will determine how doctors and nursing assistants interpret safety and risk, the centre of care (patient or professional-centred care), the concept of restraint, professional responsibilities and interventions, interactions of the team and the leadership.

Optical interference artifacts in contact atomic force microscopy images.

Atomic force microscopy images are usually affected by different kinds of artifacts due to either the microscope design and operation mode or external environmental factors. Optical interferences between the laser light reflected off the top of the cantilever and the light scattered by the surface in the same direction is one of the most frequent sources of height artifact in contact (and occasionally non-contact) images. They are present when imaging highly reflective surfaces, or even when imaging non-reflective materials deposited onto reflective ones. In this study interference patterns have been obtained with a highly polished stainless steel planchet. The influence of these artifacts in surface roughness measurements is discussed, and a semi-quantitative method based on the fast Fourier transform technique is proposed to remove the artifacts from the images. This method improves the results obtained by applying the usual flattening routines.

La reducción del uso de contenciones mecánicas, una asignatura pendiente y emergente en las UCI / Reducing the use of physical restraints, a pending and emerging matter at the ICU

No disponible

Herramientas de soporte a la decisión del uso de contenciones mecánicas en las unidades de cuidados intensivos: ¿son útiles? / Support tools for the decision to use mechanical restraints in intensive care units: Are they useful?

Antecedentes Disponemos de poca información acerca del uso de herramientas que ayuden a los enfermeros en las unidades de cuidados intensivos a decidir cuándo contener a un paciente. Los pacientes en las unidades de cuidados intensivos médico-quirúrgicas con frecuencia están con contención por su seguridad para prevenir la autorretirada de dispositivos terapéuticos. La investigación indica que las contenciones no necesariamente previenen de lesiones o de la retirada de dispositivos por parte de los pacientes. Objetivos Disminuir el uso de contenciones en una unidad de cuidados intensivos médico-quirúrgica y determinar si una herramienta de apoyo a la decisión es útil para ayudar a los enfermeros de pie de cama a determinar si se debe o no contener a un paciente. Método Un diseño de estudio cuasiexperimental se usó para este estudio piloto. Se recogieron variables para cada paciente en cada turno, indicando si hubo retiradas de dispositivos y si se usaron contenciones. Se proporcionó una actividad educativa online complementada con discusiones presenciales e individuales sobre el uso adecuado de contenciones, las alternativas y el uso de una herramienta de decisión sobre la utilización de contenciones. Se determinó la frecuencia de uso de contenciones. Se realizó estadística descriptiva y análisis temático para examinar las percepciones de los enfermeros sobre la herramienta de apoyo a la decisión. Resultados El uso de contenciones se redujo un 32%. No hubo extubaciones no planeadas o interrupción de los dispositivos terapéuticos de riesgo vital. Conclusiones Con la implementación de una herramienta de soporte a la decisión, los enfermeros disminuyeron el uso de contenciones aun manteniendo la seguridad del paciente. Una herramienta de apoyo a la decisión puede ayudar a los enfermeros que están indecisos o que necesitan confirmación de su decisión de contener o no a un paciente

No disponible

Creando un ambiente de empoderamiento en las unidades de cuidados intensivos: de la contención a la movilización / Creating an environment of empowerment in the intensive care units: From containment to mobilisation

No disponible

Uso de contenciones mecánicas en unidades de cuidados críticos: caracterización, estándares de aplicación y factores relacionados. Resultados de un estudio multicéntrico / The use of mechanical restraint in critical care units: Characterisation, application standards and related factors. Results of a multicentre study

Objetivos: Describir y caracterizar el uso de contenciones mecánicas (CM) en unidades de cuidados críticos (UCC) en términos de frecuencia y calidad de aplicación y analizar su relación con la monitorización del dolor/agitación-sedación/delirio, la ratio enfermera:paciente y la implicación institucional. Método: Estudio observacional multicéntrico realizado en 17 UCC entre febrero y mayo del año 2016. El tiempo de observación por UCC fue de 96h. Las principales variables fueron la prevalencia de contenciones, el grado de adherencia a las recomendaciones de uso de CM, la monitorización del dolor/agitación-sedación/delirio y la implicación institucional (protocolos y formación de los profesionales). Resultados: Se incluyeron 1.070 pacientes. La prevalencia general de contenciones fue del 19,11%, en pacientes con tubo endotraqueal (TET) del 42,10% y en pacientes sin TET ni vía aérea artificial del 13,92%. Se obtuvieron valores de adherencia entre el 0 y el 40% para las recomendaciones relacionadas con manejo no farmacológico y entre el 0 y el 100% para las relacionadas con la vigilancia de aspectos ético-legales. La menor prevalencia de contenciones se correlacionó con una adecuada monitorización del dolor en pacientes no comunicativos (p<0,001) y con la impartición de formación a los profesionales (p=0,020). Se halló correlación inversa entre la calidad de aplicación de CM y su prevalencia, tanto en el grupo general de pacientes ingresados en las UCC (r=−0,431) como en el subgrupo de pacientes con TET (r=−0,521). Conclusiones: Las contenciones son especialmente frecuentes en pacientes con TET/vía aérea artificial, pero también están presentes en otros pacientes que a priori no responden al perfil de uso atribuido. Las alternativas no farmacológicas al uso de CM, la vigilancia de aspectos éticos y legales y la implicación institucional presentan un amplio margen de mejora.(AU)

Objectives: To describe and characterise the use of mechanical restraint (MR) in critical care units (CCU) in terms of frequency and quality of application and to study its relationship with pain/agitation-sedation/delirium, nurse:patient ratio and institutional involvement. Method: Multicentre observational study conducted in 17 CCUs between February and May 2016. The observation time per CCU was 96h. The main variables were the prevalence of restraint, the degree of adherence to MR recommendations, pain/agitation-sedation/delirium monitoring and institutional involvement (protocols and training of professionals). Results: A total of 1070 patients were included. The overall prevalence of restraint was 19.11%, in patients with endotracheal tube (ETT) 42.10% and in patients without ETT or artificial airway it was 13.92%. Adherence rates between 0% and 40% were obtained for recommendations related to non-pharmacological management and between 0% and 100% for those related to monitoring of ethical-legal aspects. The lower prevalence of restraint was correlated with adequate pain monitoring in non-communicative patients (P<.001) and with the provision of training for professionals (P=.020). An inverse correlation was found between the quality of the use of MR and its prevalence, both in the general group of patients admitted to CCU (r=−.431) and in the subgroup of patients with ETT (r=−.521). Conclusions: Restraint is especially frequently used in patients with ETT/artificial airway, but is also used in other patients who may not meet the use profile. There is wide room for improvement in non-pharmacological alternatives to the use of MC, ethical and legal vigilance, and institutional involvement. Better interpretation of patient behaviour with validated tools may help limit use of MR.(AU)

Application of XRF spectrometry to the study of pigments in glazed ceramic pots.

Non-destructive techniques for analysis of components of a sample are very useful, and indeed essential, when the samples are unique, such as works of art, including not only pieces exhibited and preserved in museums, but also archaeological structures belonging to a historical and cultural heritage. X-ray fluorescence analysis is a suitable technique for these kinds of pieces and objects that must neither be damaged nor moved. In this work, an X-ray fluorescence spectrometer (XRFS), assembled at the University of Extremadura (Badajoz, Spain), has been applied to the study of pigments in the decorative paints of modern ceramics of known and unknown origins.

Psychometric validation of the behavioral indicators of pain scale for the assessment of pain in mechanically ventilated and unable to self-report critical care patients / Validación psicométrica de la Escala de Conductas Indicadoras de Dolor para la medición de dolor en pacientes críticos, no comunicativos y sometidos a ventilación mecánica

OBJECTIVE: To assess the psychometric properties of the behavioral indicators of pain scale (ESCID) when applied to a wide range of medical and surgical critical patients. DESIGN: A multicentre, prospective observational study was designed to validate a scale measuring instrument. SETTING: Twenty Intensive Care Units of 14 hospitals belonging to the Spanish National Health System. PARTICIPANTS: A total of 286 mechanically ventilated, unable to self-report critically ill medical and surgical adult patients. Procedure: Pain levels were measured by two independent evaluators simultaneously, using two scales: ESCID and the behavioral pain scale (BPS). Pain was observed before, during, and after two painful procedures (turning, tracheal suctioning) and one non-painful procedure. MAIN VARIABLES: ESCID reliability was measured on the basis of internal consistency using the Cronbach-_ coefficient. Inter-rater and intra-rater agreement were measured. The Spearman correlation coefficient was used to assess the correlation between ESCID and BPS. RESULTS: A total of 4386 observations were made in 286 patients (62% medical and 38% surgical). High correlation was found between ESCID and BPS (r=0.94-0.99; p < 0.001), together with high intra-rater and inter-rater concordance. ESCID was internally reliable, with a Cronbach-_ value of 0.85 (95%CI 0.81-0.88). Cronbach-_ coefficients for ESCID domains were high: facial expression 0.87 (95%CI 0.84-0.89), calmness 0.84 (95%CI 0.81-0.87), muscle tone 0.80 (95%CI 0.75-0.84), compliance with mechanical ventilation 0.70 (95%CI 0.63-0.75) and consolability 0.85 (95%CI 0.81-0.88). CONCLUSION: ESCID is valid and reliable for measuring pain in mechanically ventilated unable to self-report medical and surgical critical care patients

OBJETIVO: Evaluar las propiedades psicométricas de la Escala de Conductas Indicadoras de Dolor (ESCID), aplicada a una muestra amplia de pacientes críticos de patología médica y posquirúrgica. DISEÑO: Estudio multicéntrico, observacional, prospectivo de validación de una escala como instrumento de medida. Ámbito: Veinte Unidades de Cuidados Intensivos de 14 hospitales del Sistema Nacional de Salud español. PARTICIPANTES: Doscientos ochenta y seis pacientes críticos adultos, sometidos a ventilación mecánica, sin capacidad de comunicación, de patología médica y posquirúrgica. Intervención: Se midió el nivel de dolor de los pacientes por 2 observadores de manera simultánea y utilizando dos escalas: ESCID y la Behavoiral Pain Scale. El dolor fue medido antes, durante y después de la aplicación de dos procedimientos dolorosos (movilización y aspiración endotraqueal) y un procedimiento no doloroso. Variables de interés: La fiabilidad de ESCID se midió mediante la consistencia interna determinada con el coeficiente alfa de Cronbach. Se midió la concordancia inter- e intraobservadores. Se determinó la correlación entre las escalas ESCID y Behavoiral Pain Scale mediante el coeficiente de Spearman. RESULTADOS: Se realizaron 4.386 observaciones de dolor en 286 pacientes (62% patología médica y 38% posquirúrgica). Se evidencia una alta correlación entre ESCID y Behavoiral Pain Scale(r = 0,94-0,99; p < 0,001) así como una alta concordancia inter- e intraobservador. La escala ESCID presenta buena consistencia interna, con un valor de α-Cronbach de 0,85 (IC 95% 0,81-0,88). Los 5 dominios de ESCID presentan alta consistencia interna con α-Cronbach: musculatura facial 0,87 (IC 95% 0,84-0,89), tranquilidad 0,84 (IC 95% 0,81-0,87), tono muscular 0,80 (IC 95% 0,75-0,84), adaptación a ventilación mecánica 0,70 (IC 95% 0,63-0,75) y confortabilidad 0,85 (IC 95% 0,81-0,88). CONCLUSIÓN: ESCID es válida y fiable para medir el dolor en pacientes críticos médicos y posquirúrgicos, no comunicativos y sometidos a ventilación mecánica