Transmission of slow waves in Masimo O3 near infrared spectroscopy measures.

Introduction: Cerebral autoregulation (CA) dysfunction is a key complication following brain injury. CA assessment using near-infrared spectroscopy (NIRS) offers a promising alternative to the current non-invasive standard, cerebral blood flow velocity (CBFV) measured with transcranial Doppler. Research question: Can autoregulatory slow waves (frequency range 0.005-0.05 Hz) associated with spontaneous and induced changes in ABP in healthy volunteers be detected by parameters measured with the Masimo O3 NIRS device? Methods: ABP, CBFV and Masimo O3 parameters were measured in 10 healthy volunteers at baseline and during ABP oscillations induced by squat/stand manoeuvres. Transmission of slow waves was assessed with power spectral density and coherence analysis in NIRS signals and compared to that of CBFV. Results: At baseline, slow waves were detected with sufficient power that substantially exceeded the signals' measurement resolution in all parameters except cerebral oxygen saturation. During ABP oscillations in the 0.033 Hz range (induced by squat/stand), the power of slow waves increased in all parameters in a similar pattern, with total (cHb) and oxygenated (O2Hb) haemoglobin concentrations most closely mirroring CBFV (median standardised power [first-third quartile], baseline vs squat/stand: CBFV 0.35 [0.28-0.42] vs 0.50 [0.45-0.62], O2Hb 0.47 [0.33-0.68] vs 0.61 [0.59-0.69]). Coherence with ABP increased for both CBFV and NIRS measures from low at baseline (<0.4) to high during induced changes (>0.8). Conclusion: Spontaneous fluctuations in ABP can be observed in analysed Masimo O3 metrics to a varying degree. The clinical utility of Masimo O3 signals in CA assessment requires further investigation in brain injury patients.

Exploration of uncertainty of PRx time trends.

Introduction: PRx can be used as surrogate measure of Cerebral Autoregulation (CA) in traumatic brain injury (TBI) patients. PRx can provide means for individualising cerebral perfusion pressure (CPP) targets, such as CPPopt. However, a recent Delphi consensus of clinicians concluded that consensus could not be reached on the accuracy, reliability, and validation of any current CA assessment method. Research question: We aimed to quantify the short-term uncertainty of PRx time-trends and to relate this to other physiological measurements. Material and methods: Intracranial pressure (ICP), arterial blood pressure (ABP), end-tidal CO2 (EtCO2) high-resolution recordings of 911 TBI patients were processed with ICM + software. Hourly values of metrics that describe the variability within modalities derived from ABP, ICP and EtCO2, were calculated for the first 24h of neuromonitoring. Generalized additive models were used to describe the time trend of the variability in PRx. Linear correlations were studied for describing the relationship between PRx variability and the other physiological modalities. Results: The time profile of variability of PRx decreases over the first 12h and was higher for average PRx ∼0. Increased variability of PRx was not linearly linked with average ABP, ICP, or CPP. For coherence between slow waves of ABP and ICP >0.7, the variability in PRx decreased (R = -0.47, p < 0.001). Discussion and conclusion: PRx is a highly variable parameter. PRx short-term dispersion was not related to average ICP, ABP or CPP. The determinants of uncertainty of PRx should be investigated to improve reliability of individualised CA assessment in TBI patients.

Red solid line: Patterns of terminal loss of cerebrovascular reactivity at the bedside.

Introduction: Continuous monitoring of the pressure reactivity index (PRx) provides an estimation of dynamic cerebral autoregulation (CA) at the bedside in traumatic brain injury (TBI) patients. Visualising the time-trend of PRx with a risk bar chart in ICM + software at the bedside allows for better real-time interpretability of the autoregulation status. When PRx>0.3 is sustained for long periods, typically of at least half an hour, the bar shows a pattern called "red solid line" (RSL). RSL was previously described to precede refractory intracranial hypertension and brain death. Research question: We aimed to describe pathophysiological changes in measured signals/parameters during RSL. Material and methods: Observation of time-trends of PRx, intracranial pressure, cerebral perfusion pressure, brain oxygenation and compensatory reserve of TBI patients with RSL. Results: Three pathophysiological patterns were identified: RSL precedes intracranial hypertension, RSL is preceded by intracranial hypertension, or RSL is preceded by brain hypoperfusion. In all cases, RSL was followed by death and the RSL onset was between 1 h and 1 day before the terminal event. Discussion and conclusion: RSL precedes death in intensive care and could represent a marker for terminal clinical deterioration in TBI patients. These findings warrant further investigations in larger cohorts to characterise pathophysiological mechanisms underlying the RSL pattern and whether RSL has a significant relationship with outcome after TBI.

Candidate neuroinflammatory markers of cerebral autoregulation dysfunction in human acute brain injury.

The loss of cerebral autoregulation (CA) is a common and detrimental secondary injury mechanism following acute brain injury and has been associated with worse morbidity and mortality. However patient outcomes have not as yet been conclusively proven to have improved as a result of CA-directed therapy. While CA monitoring has been used to modify CPP targets, this approach cannot work if the impairment of CA is not simply related to CPP but involves other underlying mechanisms and triggers, which at present are largely unknown. Neuroinflammation, particularly inflammation affecting the cerebral vasculature, is an important cascade that occurs following acute injury. We hypothesise that disturbances to the cerebral vasculature can affect the regulation of CBF, and hence the vascular inflammatory pathways could be a putative mechanism that causes CA dysfunction. This review provides a brief overview of CA, and its impairment following brain injury. We discuss candidate vascular and endothelial markers and what is known about their link to disturbance of the CBF and autoregulation. We focus on human traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH), with supporting evidence from animal work and applicability to wider neurologic diseases.

Cerebrovascular Pressure Reactivity Has a Strong and Independent Association With Outcome in Children With Severe Traumatic Brain Injury.

OBJECTIVES: To examine cerebrovascular pressure reactivity index (PRx) in a large cohort of children with severe traumatic brain injury (sTBI) in association with physiologic variables and outcome. DESIGN: Retrospective observational cohort study. SETTING: Red Cross War Memorial Children's Hospital in Cape Town, South Africa. PATIENTS: Pediatric (≤ 14 yr old) sTBI patients with intracranial pressure (ICP) monitoring (postresuscitation Glasgow Coma Score [Glasgow Coma Scale (GCS)] of ≤ 8). MEASUREMENTS AND MAIN RESULTS: Data were analyzed from ICM+ files sampled at 100Hz. PRx (a mathematical indicator of pressure reactivity) was calculated as a moving correlation coefficient between ICP and mean arterial pressure (MAP) as previously described. Associations between PRx, age, GCS, ICP, MAP, and cerebral perfusion pressure (CPP) were examined with summary measures and correlation analysis using high-frequency data. Associations between PRx and mortality/outcome were examined with multivariable logistic regression analysis and the prognostic ability of PRx with receiver operating characteristic (ROCs) curves. The dataset included over 1.7 million minutes (28,634 hr) of MAP and ICP data in 196 children. The series mortality was 10.7% (21/196), and unfavorable outcome 29.6% (58/196). PRx had a moderate positive correlation with ICP ( r = 0.44; p < 0.001), a moderate negative correlation with CPP ( r = -0.43; p < 0.001), and a weak negative correlation with MAP ( r = -0.21; p = 0.004). PRx was consistently higher in patients with poor outcome and had a strong, independent association with mortality (ROC area under the curve = 0.91). A PRx threshold of 0.25 showed the best predictive ability for mortality. CONCLUSIONS: This is the largest cohort of children with PRx analysis of cerebrovascular reactivity to date. PRx had a strong association with outcome that was independent of ICP, CPP, GCS, and age. The data suggest that impaired autoregulation is an independent factor associated with poor outcome and may be useful in directing clinical care.

Hands-off? Lessons from high-touch professionals about going virtual.

The COVID-19 crisis has fundamentally changed how many businesses operate and connect with their customers. Previously unheard-of government restrictions and sheltering-in-place requirements forced most professional services to transition to remote delivery methods (e.g., email, telephone, video consults, Shopify storefronts). Providers of low-touch services (e.g., lawyers, accountants) naturally lent themselves to remote delivery; however, those that offer high-touch services, particularly those in healthcare (e.g., doctors, chiropractors, physical therapists), experienced a drastic change in working conditions when going virtual. Despite a long history of resistance to virtual delivery, the pandemic created an unprecedented incentive for these high-touch professionals to experiment with underutilized care models such as telehealth: the provision of healthcare services remotely using telecommunications technologies. We examine the rapid adoption of telehealth during COVID-19 through the coming together or convergence of previously unrelated technologies, spaces, and practices. Our analysis reveals opportunities and challenges associated with going hands-off that apply to many other professionals providing high-trust services. Specifically, we offer nine guiding principles for building and protecting cognitive and affective trust in virtual and hybrid delivery models. This is important given the pace of compounding technology convergences that lie ahead for service professionals.

Randomized Trial Comparing Instructor-Delivered Feedback with Self-Assessment Using Video during Basic Skills Training.

Feedback has been shown to be one of the most powerful and effective influences on student achievement; however, the optimal method for providing feedback to trainees during veterinary skills training has yet to be determined. A prospective mixed-methods study was undertaken to evaluate student perceptions and performance outcomes with self-assessment using video- or instructor-delivered feedback during skills training using a model. Forty participants naïve to intravenous (IV) catheter placement were randomly assigned either to self-assessment using video or to instructor-directed feedback. A questionnaire probing participants' perceptions of their knowledge level and confidence in their skills was completed before and after the training, and an interview was done at study completion. Final skill performance was recorded using video capture to permit blind evaluations using a standard assessment tool. A quantitative evaluation of the performance and questionnaire scores, as well as a qualitative assessment of the interviews, was performed. Questionnaire scores were significantly higher in the post-study questionnaire for 12 of the 14 questions in both groups. Students assigned to the instructor-directed group had significantly higher scores than students in the self-directed group on the skill performance (p < .05). Self-reported confidence in knowledge and skill related to the IV catheterization technique improved with both self-directed feedback using video and instructor-directed feedback. Skill performance, however, was superior following instructor-directed feedback. Participants expressed positive experiences associated with use of the models for skills training, the value of the learning materials including the video, and guidance during learning.

Exercise Physiologists: Key to Providing Early Mobilization in the Intensive Care Unit.

BACKGROUND: Patient immobility and a lack of physical activity in the intensive care unit results in a myriad of negative patient and hospital outcomes. OBJECTIVE: To report research findings related to the use of exercise physiologists in promoting and providing aggressive and progressive early mobilization within the intensive care unit. METHODS: This observational cohort study used the researcher-generated 12-point Activity Mobilization Evaluation Scale and delirium prevention bundle in 3 medical-surgical intensive care units to track patients' progress with mobilization. RESULTS: On average, most of the 216 patients in the study population realized a 1.6-point change (P < .001) in activity level with intervention by an exercise physiologist. Almost all of the study population (97%) maintained or increased the level of activity after receiving a minimum of 1 session with an exercise physiologist (mean, 3.5 sessions per day) during the 3-month study period. CONCLUSION: The introduction of exercise physiologists in the intensive care units proved to be a novel, safe, and effective strategy that maintained or increased the activity level of 97% of study patients.

Description of Nurse Scientists in a Large Health Care System.

Replicating a research study that described the work of nurse scientists in children's hospitals, the purpose of the study was to describe the role, activities, and outcomes of nurse scientists employed in a national health care organization. The characteristics of nurses filling the nurse scientist role in clinical settings and outcomes associated with the role have not been extensively described. The setting of this study is ideal since the organization includes facilities of various sizes located in rural, urban, and suburban areas in 18 states. Names and contact information of nurse scientists were obtained from nurse executives at each of the 110 affiliated organizations. Nurse scientists completed an anonymous survey. The primary role of the nurse scientists is to facilitate the work of others. Recommendations to strengthen the research infrastructure are provided.

Feasibility and Effectiveness of a Delirium Prevention Bundle in Critically Ill Patients.

BACKGROUND: Strategies for preventing delirium include early identification and avoiding or modifying patient, environmental, and iatrogenic factors. Minimal research exists on a prescriptive delirium prevention bundle that details elements or strategies for each bundle component. Even less research has been focused on nurse-driven interventions or components. OBJECTIVE: To evaluate the effectiveness of a delirium prevention bundle in decreasing delirium incidence in 2 medical-surgical intensive care units in a large Texas medical center. METHODS: Researchers used the Confusion Assessment Method for the Intensive Care Unit to assess delirium incidence by using a controlled interventional cohort design with 447 delirium-negative critically ill patients. Bundle components consist of sedation cessation, pain management, sensory stimulation, early mobilization, and sleep promotion. RESULTS: The intervention, analyzed by using a logistic regression model, reduced the odds of delirium by 78% (odds ratio, 0.22; P = .001). CONCLUSIONS: The delirium prevention bundle was effective in reducing the incidence of delirium in critically ill medical-surgical patients. Further validation studies are under way.

Reshaping policy to deliver holistic care for adolescents with Crohn's disease.

The number of adolescents with Crohn's disease (CD) is rising, with one third of cases diagnosed before turning 21 years old. Evidence shows that long-term medical intervention, school absence and the physical toll of CD on the growing adolescent also have a psychological effect on patients. In addition, poorly defined transition pathways are extending these problems into adulthood. The National Institute for Health and Care Excellence (NICE) guidelines are important in shaping service delivery and distribution. However, analysis of the full 2012 NICE CD management guidelines indicates they fall short of providing adequate recommendations for holistic management of the disease in young populations. An update in 2016 added a new clinical recommendation to the guidelines, but no further exploration of the psychosocial aspects of the impact of the disease. The authors of this article used a critical review of literature and concluded that service provision for adolescents with CD could be made better by improving CD support networks, involving young people in the development of policy centred on their care, as well as incorporating other (non-NICE) well-researched CD guidelines in national policy. These changes would improve quality of life for this vulnerable population.

Hospital workers bypass traditional occupational injury reporting systems when reporting patient and visitor perpetrated (type II) violence.

BACKGROUND: Under-reporting of type II (patient/visitor-on-worker) violence by workers has been attributed to a lack of essential event details needed to inform prevention strategies. METHODS: Mixed methods including surveys and focus groups were used to examine patterns of reporting type II violent events among ∼11,000 workers at six U.S. hospitals. RESULTS: Of the 2,098 workers who experienced a type II violent event, 75% indicated they reported. Reporting patterns were disparate including reports to managers, co-workers, security, and patients' medical records-with only 9% reporting into occupational injury/safety reporting systems. Workers were unclear about when and where to report, and relied on their own "threshold" of when to report based on event circumstances. CONCLUSIONS: Our findings contradict prior findings that workers significantly under-report violent events. Coordinated surveillance efforts across departments are needed to capture workers' reports, including the use of a designated violence reporting system that is supported by reporting policies. Am. J. Ind. Med. 59:853-865, 2016. © 2016 Wiley Periodicals, Inc.

The Duration of Self-Selected Music Needed to Reduce Preoperative Anxiety.

PURPOSE: Preoperative anxiety affects patients both physically and psychologically. It may also influence the patient's perioperative experience and result in reduced patient satisfaction with care and potentially delayed recovery. Previous research indicates that patients who listen to music in the perioperative setting experience less anxiety than patients who do not listen to music. Research does not address the duration of music required to effectively reduce anxiety in this population. DESIGN: A randomized control trial was used. METHODS: Two intervention groups (15-minute music and 30-minute music) and one control group (no music) were compared. FINDINGS: Patients (n = 133) demonstrated less anxiety after listening to either 15 or 30 minutes of music (P < .0001). Patients (n = 47) who listened to 15 minutes of music demonstrated less anxiety than those who did not listen to music (P = .005), whereas patients (n = 41) who listened to 30 minutes of music demonstrated less anxiety than those who did not listen to music (P < .001). CONCLUSIONS: Listening to as little as 15 minutes of music preoperatively is an effective method to reduce anxiety in patients who are about to have surgery.

An urgent need to understand and address the safety and well-being of hospital "sitters".

BACKGROUND: Hospital sitters provide continuous observation of patients at risk of harming themselves or others. Little is known about sitters' occupational safety and well-being, including experiences with patient/visitor-perpetrated violence (type II). METHODS: Data from surveys, focus groups, individual interviews at six U.S. hospitals were used to characterize the prevalence of and circumstance surrounding type II violence against sitters, as well as broader issues related to sitter use. RESULTS: Sitter respondents had a high 12-month prevalence of physical assault, physical threat, and verbal abuse compared to other workers in the hospital setting. Sitters and other staff indicated the need for clarification of sitters' roles regarding patient care and sitter well-being (e.g., calling for assistance, taking lunch/restroom breaks), training of sitters in personal safety and de-escalation, methods to communicate patient/visitor behaviors, and unit-level support. CONCLUSIONS: The burden of type II violence against hospital sitters is concerning. Policies surrounding sitters' roles and violence prevention training are urgently needed.

Physical assault, physical threat, and verbal abuse perpetrated against hospital workers by patients or visitors in six U.S. hospitals.

BACKGROUND: An elevated risk of patient/visitor perpetrated violence (type II) against hospital nurses and physicians have been reported, while little is known about type II violence among other hospital workers, and circumstances surrounding these events. METHODS: Hospital workers (n = 11,000) in different geographic areas were invited to participate in an anonymous survey. RESULTS: Twelve-month prevalence of type II violence was 39%; 2,098 of 5,385 workers experienced 1,180 physical assaults, 2,260 physical threats, and 5,576 incidents of verbal abuse. Direct care providers were at significant risk, as well as some workers that do not provide direct care. Perpetrator circumstances attributed to violent events included altered mental status, behavioral issues, pain/medication withdrawal, dissatisfaction with care. Fear for safety was common among worker victims (38%). Only 19% of events were reported into official reporting systems. CONCLUSIONS: This pervasive occupational safety issue is of great concern and likely extends to patients for whom these workers care for.

Developing curriculum recommendations for environmental health in nursing.

In 2010, the American Nurses Association (ANA) added an environmental health standard to the ANA Scope and Standards of Practice requiring that nurses implement environmental health strategies in nursing practice. To prepare nurse educators to integrate environmental health at all educational levels, nursing faculty members from the Alliance of Nurses for Healthy Environments developed environmental health competencies and curricular recommendations that address this need. Internet URLs are included for environmental health curricula for each level of nursing education.

The experience of family members of ICU patients who require extensive monitoring: a qualitative study.

A mixed methods study using family research with a phenomenological approach (n = 5 families) was conducted to explore family members' perceptions about the extensive monitoring technology used on their critically ill family member after cardiac surgery, as experienced when family members initially visited the patient in the cardiovascular intensive care unit. Five relevant themes emerged: overwhelmed by all of the machines; feelings of uncertainty; methods of coping; meaning of the numbers on the machines; and need for education.

Nursing education's response to the 1995 Institute of Medicine Report: Nursing, Health, and the Environment.

PROBLEM: Although environmental health has been central to nursing practice since the work of Florence Nightingale, the inclusion of environmental health concepts into nursing education has, for the most part, been confined to public health and occupational health nursing. The 1995 Institute of Medicine report, Nursing, Health, and the Environment, clearly stated that environmental health was an important aspect of nursing practice, but nurses were not adequately educated to address such in their practice. METHODS: This article highlights the initiatives by nurse educators, faculty development programs, federal agencies, nonprofit organizations, and private foundations to educate and engage nurses in environmental health since 1995, with a focus on the Alliance of Nurses for Healthy Environments. The historical summary was developed using professional literature, documents, personal interviews, and survey data. FINDINGS: Nurses responded to the mandates of the 1995 Institute of Medicine report, Nursing, Health, and the Environment, in formal educational programs, through continuing education for nurses, workshops, symposia, and regional faculty development trainings. Since the formation of the Alliance of Nurses for Healthy Environments, collaborative efforts led to the development of competencies, nursing outreach to organizations such as the American Nursing Association, the National Council of State Boards of Nursing, and the American Association of Colleges of Nursing to advance practice standards, academic curriculum, and the development of an electronic textbook. CONCLUSION: The environmental health nursing agenda moved forward since the publication of the 1995 IOM report; however, the development of the Alliance of Nurses for Healthy Environments accelerated the educational accomplishments through organizational collaboration.

Evaluation of a standardized hourly rounding process (SHaRP).

Current research suggests that hourly rounds on hospitalized patients may be associated with improvements in care delivery and in the patients' perception of care, as well as a reduction in patient safety events. Implementing an hourly rounding protocol involves a major change in nursing staff workflow and a substantial training and education program to ensure the success of the program. This quasi-experimental study aimed to determine if a standardized hourly rounding process (SHaRP), implemented through a formal education program, would result in improved efficiency, quality, safety, and patient satisfaction metrics when compared to a less standardized process introduced through the traditional train-the-trainer method. Data were collected over a 6-month period and results were trended for an additional 6 months later to determine if significant gains were sustained over time. Significant reductions in call light use during the study period (p = .001) and the number of steps taken by the day-shift staff (p = .02) were seen on the intervention unit. Differences in the number of patient falls, 30-day readmission rates, and patients' perception of care were not statistically significant.