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.

Exploring CRRT practices in ICU: a survey of Canadian hospitals.

BACKGROUND: Continuous renal replacement therapy (CRRT) is a highly specialized therapy not only for patients with acute renal failure, but also for patients with other critical conditions. The nursing work involved in CRRT is complex and the learning requirements are challenging to sustain ongoing competence. There are also adverse events associated with CRRT, such as those resulting from the anticoagulation therapy. Limited nursing literature is available regarding the use of CRRT by nurses in Canadian intensive care units. METHODS: In 2005, the authors conducted a national survey of CRRT nursing practices with nurse educators in intensive care units. The survey had fixed choice, as well as open-ended questions exploring various aspects of CRRT implementation, including education provided and adverse events experienced by patients. RESULTS: Of the 53 teaching and non-teaching hospitals that were sent the survey, 50 replied (94% response rate). Thirty-four of the sites used CRRT. The results reported here represent the findings from the survey questions pertaining to education and adverse events only. CONCLUSION: The results indicate that education, continuing competence, and prevention and management of adverse events, such as bleeding and filter clotting, are the major issues related to CRRT nursing practice across Canada.

Continuous Renal Replacement Therapy (CRRT) practices in Canadian hospitals: Where are we now?

BACKGROUND: Acute kidney injury (AKI) is a common complication in critically ill patients. Renal replacement therapy is prescribed for as many as 70% of critically ill patients in AKI and may be provided in the form of intermittent or continuous dialysis including intermittent hemodialysis, sustained low-efficiency dialysis, and continuous renal replacement therapy (CR RT). CRRT is commonly used for unstable critically ill patients, as it involves a slow continuous process. The nursing work involved with CR RT is highly complex and the learning requirements are challenging; therefore, it is important to identify nursing practices. PURPOSE: A national survey was conducted to gain insight into CRRT nursing practices. METHODS: T he design for this study was descriptive using a survey The target population for this survey was ICU nurse educators at Canadian teaching and community hospitals. Topics in the survey included staff education, CRRT ordering and initiation practices, vascular access, filters and filter life, fluids used, anticoagulation methods, adverse events, and greatest concerns. FINDINGS: One hundred and twenty-nine surveys were sent out and 73 were returned for a response rate of 57%. Thirty-six hospitals used CRRT and of these, 73% had used CR RT for more than eight years. The findings revealed that educators identified achieving and maintaining competence as their greatest concern related to CRRT practices. CONCLUSION: The fndings of this research revealed that consistent training programs were not the norm. The complexity of caring for patients on CRRT requires consideration of when to introduce to staff the technology and care of patients on CRRT and how to sustain their competence.

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.