Nasal cannula or high-flow oxygen for patients with COPD in acute respiratory distress?

ABSTRACT: There may be some confusion regarding the use of supplemental oxygen in patients with chronic obstructive pulmonary disease (COPD) who are experiencing acute respiratory distress. This article addresses a common nursing misconception regarding the use of high-flow oxygen administration via non-rebreather masks instead of low-flow oxygen administration via nasal cannulas in patients with COPD who are in acute respiratory distress, an issue that was investigated in a simulation education exercise and survey of the nursing staff at the authors' facility.

Nursing implications for prevention of adverse drug events in the intensive care unit.

Adverse drug events are common in the intensive care unit setting. Despite the existence of many long-standing safety principles (such as the "five rights") and new mechanisms to promote medication safety, there is still a gap between practice and the goal of patient safety. This is the result of the many human and system factors that impact care delivery. Research supports the role of the nurse as having a positive impact on patient outcomes. Future research requires the evaluation of new strategies and technologies to support safe medication administration. For example, patient simulation is being used to teach student and novice nurses principles of medication administration in a "safe" setting that more closely resembles the clinical environment. The Institute of Nursing repeatedly has stressed the need to address the organizational, technical, and human issues that impact patient safety, with an emphasis on the need to transform the nurse work environment to keep patients safe. This transformation will require a new level of interdisciplinary research and nursing involvement to address better care for our patients and, in particular, reduce adverse drug events.

Mobility interventions to improve outcomes in patients undergoing prolonged mechanical ventilation: a review of the literature.

Survivors of critical illness often undergo an extended recovery trajectory. Reduced functional ability is one of several adverse outcomes of prolonged bed rest and mechanical ventilation during critical illness. Skeletal muscle weakness is known to be one of the major phenomena that account for reduced functional ability. Although skeletal muscle weakness is evident after prolonged mechanical ventilation (PMV), few studies have tested the benefits of various types of mobility interventions in this population. The purpose of this article is to review the published research on improving mobility outcomes in patients undergoing PMV. For this review, published studies were retrieved from MEDLINE, PubMed, CINAHL, and the Cochrane Database of Systematic Reviews from January 1990 to July 2007. A total of 10 relevant articles were selected that examined the effect of whole body physical therapy, electrical stimulation (ES), arm exercise, and inspiratory muscle training (IMT). Overall, there is support for the ability of mobility interventions to improve outcomes in patients on PMV but limited evidence of how to best accomplish this goal. Generating more data from multicenter studies and randomized controlled trials is recommended.

Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit.

BACKGROUND: Many academic medical centers employ nurse practitioners as substitutes to provide care normally supplied by house staff. OBJECTIVE: To compare outcomes in a subacute medical intensive care unit of patients managed by a team consisting of either an acute care nurse practitioner and an attending physician or an attending physician and critical care/pulmonary fellows. METHODS: During a 31-month period, in 7-month blocks of time, 526 consecutive patients admitted to the unit for more than 24 hours were managed by one or the other of the teams. Patients managed by the 2 teams were compared for a variety of outcomes. RESULTS: Patients managed by the 2 teams did not differ significantly for any workload, demographic, or medical condition variable. The patients also did not differ in readmission to the high acuity unit (P = .25) or subacute unit (P = .44) within 72 hours of discharge or in mortality with (P = .25) or without (P = .89) treatment limitations. Among patients who had multiple weaning trials, patients managed by the 2 teams did not differ in length of stay in the subacute unit (P = .42), duration of mechanical ventilation (P = .18), weaning status at time of discharge from the unit (P = .80), or disposition (P = .28). Acute Physiology Scores were significantly different over time (P = .046). Patients managed by the fellows had more reintubations (P=.02). CONCLUSIONS: In a subacute intensive care unit, management by the 2 teams produced equivalent outcomes.

Effect of tracheal gas insufflation during weaning from prolonged mechanical ventilation: a preliminary study.

BACKGROUND: Tracheal gas insufflation reduces inspired tidal volume and minute ventilation in spontaneously breathing patients and may facilitate weaning from mechanical ventilation. OBJECTIVE: To determine if tracheal gas insufflation can reduce ventilatory demand during weaning trials in patients who require prolonged mechanical ventilation. METHODS: A reduction in ventilatory demand was defined as a relative decrease in tidal volume, minute ventilation, and mean inspiratory flow during trials with tracheal gas insufflation compared with the values during trials without this therapy. A total of 14 subjects underwent T-piece trials with and without insufflation (flow rate 6 L/min) on 2 consecutive days; the order of insufflation was randomized. Tidal volume, minute ventilation, and mean inspiratory flow were measured at baseline (without insufflation) and 2 hours later. RESULTS: Differences in ventilatory demand were not significant when comparisons were made for condition (tracheal gas insufflation vs no flow) or time (baseline vs 2 hours) for the total group (P = .48). Subjects were classified post hoc as responders (n = 9) or nonresponders (n = 5). Comparisons between responders and nonresponders indicated a significant (P = .02) 3-way multivariate interaction for group (responder vs nonresponder), condition (tracheal gas insufflation vs no flow), and time (baseline vs 2 hours) for ventilatory demand variables. CONCLUSION: Tracheal gas insufflation can reduce ventilatory demand during weaning trials in some patients who require mechanical ventilation.

Perceptions of physicians, nurses, and respiratory therapists about the role of acute care nurse practitioners.

BACKGROUND: Information about the contributions of acute care nurse practitioners to medical management teams in critical care settings is limited. OBJECTIVE: To examine contributions of acute care nurse practitioners to medical management of critically ill patients from the perspectives of 3 disciplines: medicine, respiratory care, and nursing. METHODS: Attending physicians, respiratory therapists, and nurses in 2 intensive care units were asked to list 3 advantages and 3 disadvantages of collaborative care provided by acute care nurse practitioners. Qualitative methods (coding/constant comparative analysis) were used to identify common themes and subthemes. Overall response rate was 35% (from 69% for attending physicians to 26% for nurses). RESULTS: Responses were grouped into 4 main themes: accessibility, competence/knowledge, care coordination/communication, and system issues. Acute care nurse practitioners were valued for their accessibility, expertise in routine daily management of patients, and ability to meet patient/family needs, especially for "long-stay" patients. Also, they were respected for their commitment to providing quality care and for their communication skills, exemplified through teaching of nursing staff, patient/family involvement, and fluency in weaning protocols. Physicians valued acute care nurse practitioners' continuity of care, patient/family focus, and commitment. Nurses valued their accessibility, commitment, and patient/family focus. Respiratory therapists valued their accessibility, commitment, and consistency in implementing weaning protocols. CONCLUSION: Responses reflected unique advantages of acute care nurse practitioners as members of medical management teams in critical care settings. Despite perceptions of the acute care nurse practitioner's role as medically oriented, the themes reflect a clear nursing focus.

Management of patients in the intensive care unit: comparison via work sampling analysis of an acute care nurse practitioner and physicians in training.

BACKGROUND: Little is known about aspects of practice that differ between acute care nurse practitioners and physicians that might affect patients' outcomes. OBJECTIVE: To determine if time spent in work activities differs between an acute care nurse practitioner and physicians in training (pulmonary/critical care fellows) managing patients' care in a step-down medical intensive care unit. METHODS: Work sampling techniques were used to collect data when the nurse practitioner had 6 months' or less experience in the role (T1), after the nurse practitioner had 12 months' experience in the role (T2), and when physicians in training provided care on a rotational schedule (nurse practitioner not present, T3). These data were used to estimate the time spent in direct management of patients, coordination of care, and nonunit activities. RESULTS: Results for T1 and T2 were similar. When T2 and T3 were compared, the nurse practitioner and the physicians in training spent approximately half their time in activities directly related to management of patients (40% vs 44%, not significantly different). The nurse practitioner spent more time in activities related to coordination of care (45% vs 18%; P < .001) and less time in nonunit activities (15% vs 37%; P < .001). CONCLUSION: The nurse practitioner and the physicians in training spent a similar proportion of time performing required tasks. Because of training requirements, physicians spent more time than the nurse practitioner in nonunit activities. Conversely, the nurse practitioner spent more time interacting with patients and patients' families and collaborating with health team members.