Critical care nurse practitioners improve compliance with clinical practice guidelines in "semiclosed" surgical intensive care unit.

This prospective study examined whether the integration of acute care nurse practitioners (ACNP) in a "semiclosed" surgical intensive care unit (SICU) model increased compliance with clinical practice guidelines (CPG). Patients were admitted to critical care services with a (a) "semiclosed"/ACNP team or (b) "mandatory consultation"/non-ACNP team. CPG compliance was significantly higher (P < .05) on the "semiclosed"/ACNP team for all 3 CPGs examined in the study.

Transthoracic echocardiography for suspected pulmonary embolism in the intensive care unit: unjustly underused or rightfully ignored?

Transthoracic echocardiography (TTE) is an established part of modern medical practice, and its use in documenting cardiac disorders has long been recognized. Since the introduction of 2-dimensional TTE, the right-sided heart chambers have become amenable to fairly accurate analysis, enabling the evaluation of morphologic and functional abnormalities associated with many cardiopulmonary diseases, including pulmonary embolism (PE). The availability of small, portable echocardiographic units combined with an increasing number of intensive care specialists trained in echocardiography makes TTE an attractive modality for the diagnosis of PE in the intensive care unit (ICU). In the ICU setting, prompt decision-making and appropriate triage of critically ill patients can facilitate early institution of therapy for PE while awaiting patient stabilization and further definitive testing. Although several prior reviews incorporate TTE in the overall approach and clinical decision algorithms pertaining to the diagnosis and treatment of pulmonary embolism, no dedicated review exists that focuses purely on TTE. We attempt to fill that gap by reviewing the available literature pertaining to use of TTE in the diagnosis of suspected PE, and by better defining the use of TTE in the ICU setting. Emphasis is placed on the use of TTE as a clinical triage tool for suspected PE.

Transthoracic echocardiography for pulmonary embolism in the ICU: finding the "right" findings.

BACKGROUND: Use of transthoracic echocardiography (TTE) in documenting cardiac disorders is well accepted. This study reviews institutional experience with TTE in the clinical setting of pulmonary embolism (PE). STUDY DESIGN: Retrospective review of surgical ICU patients who underwent TTE within 72 hours of diagnosis of PE, from January 2005 to March 2007. Collected data included symptoms, clinical suspicion of PE, preexisting conditions, operative procedures, TTE findings, presence of deep venous thrombosis, and treatments used for PE. Preexisting TTEs, when available, were compared with those obtained after acute PE. TTEs subsequent to the first post-PE study were analyzed for change in severity of findings. RESULTS: Thirty-one patients (12 men, 19 women, mean age 66 years, APACHE II 18.1) were included. Twenty-two had high, and nine had moderate, clinical suspicion for PE. Radiographic diagnosis of PE was made by computed tomography (25 of 31) and by ventilation-perfusion scans (6 of 31). Twelve of 31 patients had extremity deep venous thrombosis by duplex ultrasonography. Tricuspid regurgitation was the most common TTE finding (28 of 31), followed by pulmonary hypertension (24), dilated right ventricle (23), right heart strain (19), and underfilled, hyperdynamic left ventricle (17). Seventeen patients had previous or "baseline" echocardiograms, and when compared with the post-PE TTE, all patients demonstrated worsening in at least one TTE finding. CONCLUSIONS: This study identified findings that can be used in prospective evaluation of TTE for suspected PE. The importance of baseline TTE has also been emphasized. Additional prospective evaluation of TTE in diagnosis of suspected PE in the ICU is warranted.

Improved nurse job satisfaction and job retention with the transition from a "mandatory consultation" model to a "semiclosed" surgical intensive care unit: a 1-year prospective evaluation.

OBJECTIVE: The change from a "mandatory consultation" to a "semiclosed" surgical intensive care unit (SICU) model will impact nurses considerably. We hypothesize that nurse job satisfaction, job turnover rates, and hospital costs for temporary agency nurses will improve and these improvements will be more dramatic in SICU sections with greater involvement of a dedicated surgical critical care service (SCCS). DESIGN: Prospective longitudinal survey. SETTING: Tertiary-care university hospital. SUBJECTS: SICU staff nurses. INTERVENTIONS: Change from mandatory consultation to semiclosed SICU. MEASUREMENTS AND MAIN RESULTS: We surveyed SICU nurses during the year-long transition to a semiclosed SICU service (five time points, 3-month intervals). The first four surveys included ten questions on nurse job satisfaction. The final survey included two additional questions. All questions were on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Nurse job turnover rates and money spent on agency nurses were compared over time; 503 of a possible 914 surveys were completed (55% overall return rate). Nurse job satisfaction scores significantly improved over time for all questions (p < .05). Hospital spending on agency nurses decreased significantly (p = .0098). The yearly nurse job turnover rate dropped from 25% to 16% (p = .15). The scores for both year-end statements ("I am more satisfied with my job now than 1 year ago" and "The SCCS management of all orders has improved my job satisfaction") were significantly higher in sections with greater SCCS involvement (p = .0070 and p < .0001). CONCLUSIONS: Nurse job satisfaction improved significantly with the transition to a semiclosed SICU. This higher satisfaction was associated with a significant decrease in spending on temporary agency nurses and a trend toward increased staff nurse job retention. SICU sections with greater SCCS involvement had more dramatic improvements. This semiclosed SICU model may help retain SICU nurses in a competitive job market in which experienced nurses are in short supply.