Learning end-of-life care in ICU: strategies for nurses new to ICU.

The experience of critical care nurses caring for patients and families during the withdrawal of life support has recently been explored (Vanderspank-Wright, Fothergill Bourbonnais, Brajtman, & Gagnon, 2011). In that study, the nurses were able to find, using their developing knowledge and experience, their own way, over time, through the process of withdrawing life support. Challenges in caring for patients and families were described by the participants in themes such as "the runaway train of technology," which explored nurses' experience of caring in a technologically complex environment. In this current article, the authors will explore the importance of providing "good care" in relation to withdrawal of life-sustaining treatment. The principles of providing "good care" such as patient comfort, open and frequent communication with families, support by fellow co-workers and time to reflect on the care given are fundamental to the overall experience of providing quality end-of-life care in the critical care environment. Practical solutions will be offered to help both new graduates and nurses who are new to ICU, find their way to care for patients and families within this context.

Intensive care nurses' assessment of pain in patients who are mechanically ventilated: How a pilot study helped to influence practice.

BACKGROUND: Pain is a common experience among patients in intensive care units (ICUs). Many patients in ICUs have difficulty communicating their pain because of mechanical ventilation, and issues can arise when the nurse attempts to interpret the severity of pain,and work towards effective pain management. PURPOSE: The aim of this study was to determine the suitability of the Critical-Care Pain Observation Tool (CPOT) as an assessment tool to be used by ICU nursing staff to assess pain in adult. patients who are mechanically ventilated. METHODS: This pilot study was descriptive in design and employed both quantitative and qualitative methods. Quantitative data resulted from the CPOT scores obtained. In addition, a data collection sheet, developed by the authors, recorded sedation and analgesia used and interventions provided. This separate sheet was completed each time the CPOT was used. Nurses were asked to evaluate the CPOT using a Likert scale. Qualitative data were collected through open-ended questions related to using the CPOT Results. Twenty-three participants each assessed pain five times in a total of 23 patients using the CPOT over a 12-hour shift. Nurses stated the tool was easy to use and that it would be helpful to them. CONCLUSION: The results of this pilot study contributed to the decision to implement the CPOT at the study ICUs. The systematic use of a tool may promote more goal-directed management of pain.

Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia.

PURPOSE: Several modalities have been shown to be individually effective in reducing the incidence (and hence associated morbidity, mortality, and costs) of ventilator-associated pneumonia, but their implementation into clinical practice is inconsistent. We introduced an intensive care unit protocol and measured its effect on ventilator-associated pneumonia. METHODS: A multidisciplinary team constructed a multifaceted protocol incorporating low risk and low cost strategies, many of which had independent advantages of their own. Some components were already in use, and their importance was emphasized to improve compliance. New strategies included elevation of the head of the bed, transpyloric enteral feeding, and antiseptic mouthwash. The approach to implementation and maintenance included education, monitoring, audits and feedback to encourage compliance with the protocol. RESULTS: The implementation of this prevention protocol reduced the incidence of ventilator-associated pneumonia from a baseline of 94 cases per year or 26.7 per 1,000 ventilator days to 51.3 per year or 12.5 per 1,000 ventilator days, i.e., about 50% of the pre-protocol rate (P < 0.0001). CONCLUSION: Adherence to simple and effective measures can reduce the incidence of ventilator-associated pneumonia. The protocol described was inexpensive and effective, and estimated savings are large. Implementation and maintenance of gains require a multidisciplinary approach, with buy-in from all team members, and ongoing monitoring, education, and feedback to the participants.