The comparison of the Nursing Activities Score and TrendCare to accurately measure critical care nursing workload: A prospective observational design.

INTRODUCTION: Intensive care units commonly use the Nursing Activities Score (NAS) to measure nursing workload, however, some settings use TrendCare. Historically 100 NAS points reflected one nurse, however research now suggests greater than 61 NAS points per nurse increases hospital mortality. OBJECTIVES: To determine if: 1) TrendCare accurately reflects critical care nursing workload as measured by the NAS and 2) the required nursing hours calculated by each of the scoring systems differed between indigenous and non-indigenous patients. METHODS: Using a prospective observational design, data were collected between 9 August - 25 November 2021. Nursing workload was assessed over three shifts using TrendCare and the NAS. RESULTS: Analysis included 183 patients and 829 TrendCare and NAS scores. The mean NAS for intensive care patients was >61 on all three shifts (morning M = 67.1 ± 18.2, afternoon M = 66.1 ± 18.1, night M = 64.0 ± 18.1). The mean NAS for high dependency patients (morning M = 46.1 ± 11.1, afternoon M 45.9 ± 11.0, night Mdn 46.1 [40.5-54.1]) identified a nurse:patient ratio of 1:2 reflected a NAS >90. The NAS and TrendCare found no difference in nursing hours between indigenous and non-indigenous patients, however higher scores for respiratory (H = 7.3, p = <.01), cardiovascular (H = 12.7, p = <.001) and renal (H = 12.7, p = <.001) support, and care for relatives and patients (H = 13.8, p = <.001) on some shifts were identified in indigenous patients. CONCLUSION: TrendCare nursing hours likely reflect a 1:1 nurse: patient ratio for intensive care patients but likely under-estimates high dependency care nursing workload. The NAS activities highlighted some activities required more time for indigenous patients on some shifts. IMPLICATIONS FOR CLINICAL PRACTICE: TrendCare likely reflects intensive care nursing workload but not high dependency nursing workload. A NAS of no greater than 61 points per nurse better reflects nursing workload in both the intensive and high dependency care units. Indigenous patients may require more nursing hours for nursing activities related to severity of illness.

Removing modifications to the New Zealand Early Warning Score- does ethnicity matter? A multimethod research design.

BACKGROUND: Previous research on a modified New Zealand Early Warning Score (M-NZEWS) used in predominately medical ward patients identified removing the modifications would significantly reduce the number of M-NZEWSs triggering the medical emergency team (MET), particularly in Maori patients. AIM: To firstly, explore the impact of removing the modifications from the M-NZEWS on medical and surgical ward patients' early warning score MET triggers and secondly, determine if the M-NZEWS MET triggers resulted in MET activations and if the MET activations were a result of M-NZEWS MET triggers. METHOD: The study used a multimethod research design. Phase one analysed ward electronic vital sign data and phase two analysed MET and critical care outreach data from the critical care outreach data base. RESULTS: Data of 353 patients and 1004 M-NZEWS MET triggers were analysed. Removing the modifications would result in 26.9% fewer patients with MET triggers, with the biggest impact on Maori. Only 45.8% of M-NZEWS MET triggers were escalated to the MET with 58.9% escalated to critical care outreach. Review of the MET activations identified only 59.2% had M-NZEWSs triggering the MET recorded in the electronic vital sign system; however the critical care outreach data base identified most of the MET activations were because of M-NZEWS MET triggers. CONCLUSION: Removing the modifications would significantly reduce the number of MET triggers, particularly in Maori patients. Analysing solely electronic vital sign data may not reflect the number of medical emergency team triggers or activations.

The impact of a modified New Zealand Early Warning Score (M-NZEWS) and NZEWS on ward patients triggering a medical emergency team activation: A mixed methods sequential design.

INTRODUCTION: Limited research exists on the effectiveness of the New Zealand Early Warning Score (NZEWS). AIM: To determine the impact of a modified NZEWS (M-NZEWS) and NZEWS on ward patients' medical emergency team activation triggers. RESEARCH DESIGN: Mixed methods sequential design. METHODS: Three phases included: 1) review of M-NZEWS electronic data to determine the effect of a M-NZEWS and NZEWS on ward patients; 2) an in-depth review of 20 Maori patients allocated to lower escalation zones if the NZEWS were adopted and 3) the number of electronic medical emergency team activation triggers compared to the number of actual medical emergency team activations. RESULTS: 1255 patients and 3505 vital sign data sets were analysed. Adopting the NZEWS would result in 396 (26.8%) fewer patients triggering a medical emergency team activation. The biggest impact would be on Maori, with 38.6% of Maori allocated to a lower escalation zone. Only 51.2% of patients with a medical emergency team activation had vital signs triggering the response electronically documented. CONCLUSION: Changing from the M-NZEWS to NZEWS will reduce the number of medical emergency team activation triggers, with the biggest impact on Maori. Electronic vital sign data does not accurately reflect the number of ward medical emergency team triggers or activations.

Nasal high flow oxygen therapy in the ward setting: A prospective observational study.

BACKGROUND: Whilst research demonstrates the benefits of nasal high flow oxygen in the intensive care setting, limited literature exists on its benefits in ward patients. OBJECTIVES: This study evaluated the use of nasal high flow oxygen in adult ward patients with respiratory failure or at risk of respiratory deterioration. Primary outcome was an improvement in pulmonary function as indicated by decreases in respiratory and heart rates and an increase in arterial oxygen saturation via pulse oximetry. RESEARCH METHODOLOGY: Using a prospective observational research design, purposeful sampling recruited 67 adult ward patients receiving nasal high flow oxygen between May and July 2015 (inclusive). All recruited patients were included in the data analysis. RESULTS: The median age was 71.0 years (q25, q75=58.0, 78.0) and most patients were medical specialty patients (n=46, 68.7%). After commencing nasal high flow oxygen, respiratory rate (t=2.79, p=<0.01) and heart rate (t=2.23, p=0.03) decreased and arterial oxygen saturation via pulse oximetry increased (t=4.08, p=<0.001). CONCLUSION: Nasal high flow oxygen appears effective in a selective group of ward patients with respiratory failure, or at risk of respiratory deterioration, and may reduce demand on critical care beds; this warrants further research.

Documentation of cardiopulmonary resuscitation decisions in a New Zealand hospital: A prospective observational study.

INTRODUCTION: Documentation of cardiopulmonary resuscitation (CPR) decisions is often poor. Lack of documented decisions risks inappropriate CPR and staff, patient and family distress. OBJECTIVE: To examine documented evidence of CPR decisions. METHOD: Using a prospective observational design, case notes of current patients in 16 wards were reviewed for documented evidence of CPR decisions. Data were collected over a consecutive two-day period in April 2015. RESULTS: 151 patients case notes were reviewed; 41 (27.2%) patients had documented decisions and 110 (72.8%) had no decisions documented. When compared to patients with no documented decisions, those with documented decisions were older (p≤0.001), had a greater number of admission days at time of data collection (p=0.02) and more comorbidities (p≤0.001). In those with documented decisions, advancing age was related to a greater number of comorbidities (p=0.02) but not to an increased number of admission days at time of data collection (p=0.81). In the non-documented group advancing age was related to both an increased number of admission days at time of data collection (p≤0.001) and a greater number of comorbidities (p≤0.001). CONCLUSION: Documentation of CPR decisions is suboptimal. Improving documentation reduces staff, patient and family distress and allows appropriate and dignified end of life care.

The effectiveness of a patient at risk team comprised of predominantly ward experienced nurses: A before and after study.

INTRODUCTION: Improving care to deteriorating ward patients require systems to trigger a response and a response team. This paper describes the effectiveness of a Patient at Risk team (PART) comprised predominantly of experienced ward nurses. METHOD: The study used a single site before and after historical control design. The number of medical emergency team (MET) calls, cardiac arrest calls and hospital admissions occurring prior to the establishment of the PART (January-December 2008 inclusive) were compared to those occurring after the team was established (January 2011-December 2012 inclusive). Primary outcome was the number of MET and cardiac arrest calls per 1000 hospital admissions. RESULTS: The introduction of the PART resulted in a significant reduction in ward cardiac arrests per 1000 admissions (MD = 0.9, 95% CI: 0.3-1.5, p = 0.009), hospital length of stay per 1000 admissions (MD = 294.4, 95% CI: 260.9-328.7, p ≤ 0.001) and direct ward admissions to ICU (95% CI: 0.7-5.2) but no change in the number of MET calls per 1000 admissions (MD = 1.3, 95% CI: -2.3-4.9, p = 0.46). CONCLUSION: A PART comprising of experienced ward nurses was associated with reduced ward cardiac arrests but no change in the number of MET calls. This suggests this team composition may be effective in providing care to the deteriorating patient.

Nurse practitioners versus doctors diagnostic reasoning in a complex case presentation to an acute tertiary hospital: a comparative study.

BACKGROUND: Nurse practitioners perform a diagnostic role previously delivered by doctors. Multiple studies demonstrate nurse practitioners are as effective as doctors when managing chronic conditions and minor illnesses and injuries. No studies have focused on how nurse practitioners compare to doctors in their management of complex cases presenting for the first time. OBJECTIVE: This study assessed how nurse practitioners' diagnostic reasoning abilities when managing a complex case compared to those of doctors'? DESIGN: A comparative research design. PARTICIPANTS: Purposeful sampling recruited 30 nurse practitioners and 16 doctors working in multiple specialties in New Zealand. All doctors were completing postgraduate specialist training programmes. Specialties included older adults, emergency care, primary health care/general practice, cardiology, respiratory and palliative care. METHODS: A complex case scenario assessed by an expert panel and think aloud protocol was used to assess diagnostic reasoning abilities. The ability of 30 nurse practitioners to determine diagnoses, identify the problem, and propose actions was compared to that of 16 doctors. Correct responses were determined by an expert panel. Data gained from the case scenario using think aloud protocol were quantified for analysis. RESULTS: 61.9% of doctors identified the correct diagnoses, 56.3% the problem and 34.4% the actions as determined by the expert panel. This compares to 54.7% of nurse practitioners identifying the correct diagnoses, 53.3% the problem and 35.8% the actions. Analysis revealed no difference between these groups (diagnoses 95% CI: -1.76 to -0.32, p=0.17, problem χ(2)=0.00, p=1.0, or actions 95% CI: -1.23 to 1.58, p=0.80). CONCLUSION: Nurse practitioners' diagnostic reasoning abilities compared favourably to those of doctors in terms of diagnoses made, problems identified and action plans proposed from a complex case scenario. In times of global economic restraints this adds further support to alternative models of care.

Using a combined nursing and medical approach to reduce the incidence of central line associated bacteraemia in a New Zealand critical care unit: a clinical audit.

OBJECTIVE: Research suggests a median central line associated bacteraemia rate of zero is achievable. This paper outlines the effectiveness of using a combined nursing and medical approach in reducing central line associated bacteraemia in a New Zealand critical care unit. METHOD: The study used a before and after audit design. Data collected between October 2007 and December 2008 prior to introducing a central line associated bacteraemia insertion bundle were compared to data collected between January 2009 and April 2011 when insertion, maintenance and high risk patient bundles were sequentially introduced. RESULTS: Data collected between October 2007 and December 2008 identified a mean central line associated bacteraemia rate of 6.43 per 1000 catheter days (range=0-12.30, Mdn=6.3, SD 3.34). Introducing the insertion bundle significantly decreased the mean central line associated bacteraemia rate to 1.50 (range=0-10.5, Mdn=0, SD=3.97, p=.02). Introducing a maintenance and high risk patient bundle sustained a median central line associated bacteraemia rate of zero over the following 12-month period. CONCLUSION: The study demonstrated a combined nursing and medical approach using central line bundles was effective in reducing the central line associated bacteraemia rate per 1000 line days and sustaining a median central line associated bacteraemia rate of zero.

A critical care nurse practitioner's prescribing using standing orders and authorised prescribing when performing a critical care outreach role: a clinical audit.

OBJECTIVE: This paper assesses the frequency of prescribing and the types of medications prescribed by a New Zealand critical care nurse practitioner (NP) whilst performing a critical care outreach role. METHOD: A before and after audit was conducted from June 2006 to July 2008. Audit data were collected prospectively and analysed retrospectively. Data collected between July 2006 and June 2007 when standing orders were used were compared to data collected between July 2007 and June 2008 when the NP was authorised to prescribe. Data were analysed using count, chi-square, the Fisher's Exact Test and Phi. FINDINGS: The NP completed 1061 patient visits. When compared to using standing orders, the NP prescribed a greater number and a wider range of medications when authorised to prescribe (χ2=9.280, p=.002, Φ=.094). Electrolytes and analgesics were the most common medications prescribed in both audit periods. CONCLUSION: The results provide insight into critical care NP prescribing practice to better inform future critical care workforce development.

Local experience with the use of sustained low efficiency dialysis for acute renal failure.

Renal replacement therapy (RRT) is a common therapy used to treat critically ill patients in acute renal failure. Currently a number of dialysis modalities are used such as haemodialysis, continuous renal replacement therapy (CRRT), and sustained low efficiency dialysis (SLED). As SLED is a recently implemented RRT, very little literature is available on the nursing aspects of SLED. This paper shares the local nursing experience of using SLED, thus providing a nursing perspective. Between 2002 and 2006, 103 patients were treated with SLED resulting in 307 SLED treatments. Early problems encountered involved patient hypotension, dialysis catheter patency and water quality; all of which were overcome by initially commencing dialysis at a lower prescribed blood pump rate, using larger catheters and improving water quality. Nursing advantages of SLED over CRRT included being able to release the patient for nursing activities and patient transfer out of the ICU for investigations and procedures; reduced nursing workload related to less machine and patient monitoring during the dialysis procedure; and cost reduction. Disadvantages of SLED are related to poor water quality, accessibility of water supply and limited space to house the two machines required. SLED has proven to be a nurse friendly dialysis modality for critically ill patients with acute renal failure.

The role and effectiveness of a nurse practitioner led critical care outreach service.

Research measuring the effectiveness of critical care outreach (CCOR) has been mixed. The objective of this paper is to describe the role and effectiveness of a nurse practitioner (NP) led critical care outreach service (CCORS). Using a comparative study design, data on the number of intensive care unit (ICU) readmissions <72h were analysed 12 months prior to, and 12 months following implementation of the service. Data was also collected on length of stay and APACHE II scores of ICU readmissions <72h, ICU patient acuity, ICU readmission mortality, and ward medical emergency team (MET) and cardiac arrest calls. Data on NP referrals were collected to identify NP activities. Data analysis was completed using descriptive statistics and run and control charts. There were 133 NP referrals, which resulted in 525 patient visits. The most common interventions completed by the NP during visits included requesting of diagnostic tests and prescribing. Following introduction of the NP CCORS, there was a sustained reduction in ICU readmissions <72h. In conclusion, a NP led CCORS has a positive effect on patient outcomes and supports development of further NP positions.

The level of knowledge of respiratory physiology articulated by intensive care nurses to provide rationale for their clinical decision-making.

The combination of intensive care knowledge, and the ability to articulate analytical decision-making processes to the interdisciplinary team, enhances the clinical credibility of the intensive care unit (ICU) nurse. The objective of this paper is to outline a study firstly, assessing ICU nurses' ability in articulating respiratory physiology to provide rationale for their clinical decision-making and secondly, the barriers that limit the articulation of this knowledge. Using an evaluation methodology, multiple methods were employed to collect data from 27 ICU nurses who had completed an ICU education programme and were working in one of two tertiary ICUs in New Zealand. Quantitative analysis showed that nurses articulated a low to medium level of knowledge of respiratory physiology. Thematic analysis identified the barriers limiting this use of respiratory physiology as being inadequate coverage of concepts in some ICU programmes; limited discussion of concepts in clinical practice; lack of clinical support; lack of individual professional responsibility; nurses' high reliance on intuitive knowledge; lack of collaborative practice; availability of medical expertise; and the limitations of clinical guidelines and protocols. These issues need to be addressed if nurses' articulation of respiratory physiology to provide rationale for their clinical decision-making is to be improved.

Local experience with the use of nasal bubble CPAP in infants with bronchiolitis admitted to a combined adult/paediatric intensive care unit.

Bronchiolitis is an acute inflammatory disease of the lower small airways predominantly occurring in infants younger than 1 year of age. As a result of the respiratory distress associated with bronchiolitis, infants frequently require admission to an intensive care unit for respiratory support. Thirty-five infants diagnosed with bronchiolitis were admitted to a combined adult/paediatric tertiary intensive care unit over a 2-year period for nasal bubble continuous positive airway pressure (CPAP). Following this therapy, 20 (57.14%) of these infants could be transferred to the medical ward of the onsite paediatric hospital. The remainder required transfer to the national paediatric intensive care unit (PICU) for ongoing observation and/or positive pressure ventilation. Nasal bubble CPAP is a simple therapy that can be easily set up at the bedside. The use of nasal bubble CPAP enabled infants to remain in their geographical area, thus improving family visiting access and reducing the demand for paediatric beds in the national PICU.

A preoperative scoring system to identify patients requiring postoperative high dependency care.

INTRODUCTION: The incidence of postoperative complications is reduced with early identification of at risk patients and improved postoperative monitoring. OBJECTIVE: A nursing preoperative assessment tool was developed to identify patients at risk of postoperative complications and to reduce the number of acute admissions to ICU/HDU. METHOD: All surgical patients admitted to a surgical ward for an elective surgical procedure (n=7832) over a 23-month period were concurrently scored on admission using the preoperative assessment tool. RESULTS: During the time period studied, acute admissions to ICU/HDU reduced from 40.37 to 19.11%. DISCUSSION: Only 24.04% of patients who had a PAS >4 were identified by the surgeon and/or anesthetist as being at risk of a postoperative complication, or if identified, no provision was made for improved postoperative monitoring. This supports the need for nurses to be involved in identifying preoperatively patients at risk of a postoperative complication and in need of improved postoperative monitoring. The postoperative monitoring requirements for the PAS >4 patients were relatively low technology interventions. CONCLUSION: The preoperative assessment tool is a simple and effective tool for nurses to identify patients at risk of postoperative complications and reduces the number of acute admissions to ICU/HDU.

Utilizing TISS to differentiate between intensive care and high-dependency patients and to identify nursing skill requirements.

INTRODUCTION: An identification system utilizing the therapeutic intervention scoring system (TISS) was developed to differentiate between intensive care and high-dependency unit (HDU) patients. OBJECTIVE: To overcome the staff recruitment and retention problem, ward nursing staff were recruited into the unit. To ensure patient care requirements did not exceed nursing skill level, TISS was utilized to differentiate ICU from HDU patients and to identify nursing skill requirements. METHOD: All patients admitted to the unit over a 23-month period were concurrently TISS scored utilizing TISS -76 on admission (O/A), at 4-6 hours, day 1, day 2 and on discharge. Concurrent data on age, medical history, type of surgery and length of stay were collected. RESULTS: There were a total of 450 patients. Interventions utilized were mainly 1-, 2- and 3-point TISS values. The study identified the HDU patient group as being older, having a higher incidence of cardiac history and a shorter length of stay. The ICU patient group was identified as having undergone more major surgery. CONCLUSION: TISS is an effective triage tool for differentiating between ICU and HDU patients and identifying nursing skill requirements to care for the ICU and HDU patient groups.