Honoring Patient Requests: A Volunteer Initiative to Support the Presence of Advance Directives.

Hospitals seeking to support advance care planning and the execution of advance directives face challenges in matching patient readiness with the availability of knowledgeable personnel and resources. A volunteer-based advance directive team represents an innovative approach to providing personalized, timely, and accurate information about advance directives and assisting patients with their completion.

Implementing a Multidisciplinary Prone Positioning Team.

ABSTRACT: The coronavirus disease 2019 pandemic has escalated clinical needs while interrupting regular processes and straining resources. Striving to deliver optimal care to infected patients with respiratory failure, Rush University Medical Center in Chicago created a multidisciplinary team to provide manual prone positioning safely and efficiently. Team members' experiences, which they shared through a survey, help to illustrate the advantages of a multidisciplinary approach and suggest opportunities to enhance the effectiveness of such a team.

Retired Nurse Volunteers.

: Given the looming shortage of RNs, a viable option for hospitals to consider in optimizing available resources is the retired nurse volunteer. This article describes the benefits of using retired nurses to complement existing hospital staff and offers recommendations for setting up a program to effectively use these volunteers in the hospital setting.

Capnometry and air insufflation for assessing initial placement of gastric tubes.

BACKGROUND: Nurses are often responsible for placement of large-bore gastric tubes. Tube misplacement into the lungs is a potential complication with serious sequelae. The reliability of common bedside methods for differentiating between pulmonary and gastric placement has not been acceptable. OBJECTIVE: To compare the accuracy of capnometry (colorimetric indicator of end-tidal carbon dioxide) and air insufflation/auscultation with the accuracy of radiography in detecting the location of gastric tubes. METHODS: A prospective convenience sample of insertions of Salem sump gastric tubes was studied. Tubes were inserted by nurses according to the unit's standard procedure, and air insufflation/auscultation, capnometry, and radiography were used to detect the position of the tubes. Results obtained with each of the methods were compared. RESULTS: A total of 91 tube placements were studied in 69 patients. No radiographically documented instances of lung placement occurred. Capnometry incorrectly indicated 15 of 91 gastric placements (16%) as placements in the lung. Air insufflation/auscultation incorrectly indicated 5 of 91 gastric placements (5%) as placements in the lung. CONCLUSIONS: Neither air insufflation nor capnometry is a fail-safe method for determining placement of gastric tubes. Radiography remains the preferred method.

Antibiotic therapy for pulmonary exacerbations in adults with cystic fibrosis.

Individuals with CF are living longer but often with chronic lung infections. Effective antibiotic therapy is necessary to treat life-threatening infectious exacerbations. Knowledge of the particular requirements of antibiotic therapy for the patient with CF allows the nurse to anticipate management plans, prepare for inpatient and outpatient care, and assess response to treatment.

Moral distress of staff nurses in a medical intensive care unit.

BACKGROUND: Moral distress is caused by situations in which the ethically appropriate course of action is known but cannot be taken. Moral distress is thought to be a serious problem among nurses, particularly those who practice in critical care. It has been associated with job dissatisfaction and loss of nurses from the workplace and the profession. OBJECTIVES: To assess the level of moral distress of nurses in a medical intensive care unit, identify situations that result in high levels of moral distress, explore implications of moral distress, and evaluate associations among moral distress and individual characteristics of nurses. METHODS: A descriptive, questionnaire study was used. A total of 28 nurses working in a medical intensive care unit anonymously completed a 38-item moral distress scale and described implications of experiences of moral distress. RESULTS: Nurses reported a moderate level of moral distress overall. Highest levels of distress were associated with the provision of aggressive care to patients not expected to benefit from that care. Moral distress was significantly correlated with years of nursing experience. Nurses reported that moral distress adversely affected job satisfaction, retention, psychological and physical well-being, self-image, and spirituality. Experience of moral distress also influenced attitudes toward advance directives and participation in blood donation and organ donation. CONCLUSIONS: Critical care nurses commonly encounter situations that are associated with high levels of moral distress. Experiences of moral distress have implications that extend well beyond job satisfaction and retention. Strategies to mitigate moral distress should be developed and tested.

Outcomes associated with enteral tube feedings in a medical intensive care unit.

UNLABELLED: BACKGROUND Underfeeding of patients reliant on enteral tube feedings most likely is due primarily to interruptions in the infusions. Strategies to improve energy intake require an understanding of such interruptions and associated outcomes. OBJECTIVES: To compare daily energy intake with goal energy intake; to ascertain frequency, duration, and reasons for interruptions in feedings, and to determine occurrences of feeding intolerance. METHODS: A prospective, descriptive study of a convenience sample of patients admitted during a 3-month period to a medical intensive care unit. Patients were included who were expected to receive continuous enteral tube feedings for at least 48 hours. Patients were studied until discontinuation of feedings, discharge from the unit, or death. RESULTS: Thirty-nine patients were studied for 276 feeding days. Patients received a mean of 64% of goal energy intake. Mean length of interruptions in feeding was 5.23 hours per patient per day. Interruptions for performance of tests and procedures accounted for 35.7% of the total cessation in feeding time. Next most time-consuming interruptions occurred with changes in body position (15%), unstable clinical conditions (13.5%), high gastric residual volume (11.5%), and nausea and vomiting (9.2%). Patients had diarrhea 105 (38%) of 276 feeding days. Gastric residual volumes exceeded 150 mL on 28 measurements in 11 patients. Five patients experienced episodes of nausea and vomiting. Four patients experienced an episode of feeding aspiration. CONCLUSIONS Precautionary interruptions in enteral feedings to decrease presumed risk of aspiration occurred frequently and resulted in underfeeding. Episodes of vomiting and of aspiration were uncommon.

The application of intermittent pneumatic compression devices for thromboprophylaxis: AN observational study found frequent errors in the application of these mechanical devices in ICUs.

OBJECTIVE: Because venous thromboembolism (VTE) can be a devastating consequence of critical illness, patients should receive thromboprophylaxis using chemical or mechanical strategies or both. Mechanical strategies such as intermittent pneumatic compression (IPC) devices are in widespread use; this study sought to assess clinicians' adherence to ordered IPC devices in critically ill patients. METHODS: A month-long prospective, observational study was conducted in a convenience sample of 108 mechanically ventilated patients in four adult ICUs in an urban academic medical center. Observations of prescribed IPC device applications were made twice daily by nurses using a standardized checklist. RESULTS: Nine hundred sixty-six observations were made of 108 patients, 47 (44%) of whom were ordered to receive thromboprophylaxis with IPC devices alone and 61 (56%) to receive IPC devices in combination with an anticoagulant. Errors in IPC device application were found in 477 (49%) of the observations. Patients received no IPC prophylaxis in 142 (15%) of total observations. In 45 of 342 (13%) of the observations, IPC devices were the only type of thromboprophylaxis ordered. Half of the misapplications related to improper placement of sleeves to legs. Misapplications did not differ in type or frequency between shifts. IMPLICATIONS: The researchers observed frequent misapplications of ordered IPC devices. Future study is necessary to illuminate the consequences of such errors.

Efficacy and safety of dopamine versus norepinephrine in the management of septic shock.

The optimum septic shock vasopressor support strategy is currently debated. This study was performed to evaluate the efficacy and safety of norepinephrine (NE) and dopamine (DA) as the initial vasopressor in septic shock patients who were managed with a specific treatment protocol. A prospective, randomized, open-label, clinical trial was used in a medical intensive care unit comparing DA with NE as the initial vasopressor in fluid-resuscitated 252 adult patients with septic shock. If the maximum dose of the initial vasopressor was unable to maintain the hemodynamic goal, then fixed-dose vasopressin was added to each regimen. If additional vasopressor support was needed to achieve the hemodynamic goal, then phenylephrine was added. The primary efficacy end point was all-cause 28-day mortality. Secondary end points included organ dysfunction, hospital and intensive care unit length of stay, and safety (primarily occurrence of arrhythmias). The 28-day mortality rate was 50% (67/134) with DA as the initial vasopressor compared with 43% (51/118) for NE treatment (P = 0.282). There was a significantly greater incidence of sinus tachycardia with DA (24.6%; 33/134) than NE (5.9%; 7/118) and arrhythmias noted with DA treatment (19.4%; 26/134) compared with NE treatment (3.4%; 4/118; P < 0.0001), respectively. Logistic regression analysis identified Acute Physiologic and Chronic Health Evaluation II score (P < 0.0001) and arrhythmia (P < 0.015) as significant predictors of outcome. In this protocol-directed vasopressor support strategy for septic shock, DA and NE were equally effective as initial agents as judged by 28-day mortality rates. However, there were significantly more cardiac arrhythmias with DA treatment. Patients receiving DA should be monitored for the development of cardiac arrhythmias (NCT00604019).

Reducing use of indwelling urinary catheters and associated urinary tract infections.

BACKGROUND: Use of indwelling urinary catheters can lead to complications, most commonly catheter-associated urinary tract infections. Duration of catheterization is the major risk factor. These infections can result in sepsis, prolonged hospitalization, additional hospital costs, and mortality. OBJECTIVES: To implement and evaluate the efficacy of an intervention to reduce catheter-associated urinary tract infections in a medical intensive care unit by decreasing use of urinary catheters. METHODS: Indications for continuing urinary catheterization with indwelling devices were developed by unit clinicians. For a 6-month intervention period, patients in a medical intensive care unit who had indwelling urinary catheters were evaluated daily by using criteria for appropriate catheter continuance. Recommendations were made to discontinue indwelling urinary catheters in patients who did not meet the criteria. Days of use of a urinary catheter and rates of catheter-associated urinary tract infections during the intervention were compared with those of the preceding 11 months. RESULTS: During the study period, 337 patients had a total of 1432 days of urinary catheterization. With use of guidelines, duration of use was significantly reduced to a mean of 238.6 d/mo from the previous rate of 311.7 d/mo. The number of catheter-associated urinary tract infections per 1000 days of use was a mean of 4.7/mo before the intervention and zero during the 6-month intervention period. CONCLUSIONS: Implementation of an intervention to judge appropriateness of indwelling urinary catheters may result in significant reductions in duration of catheterization and occurrences of catheter-associated urinary tract infections.

Improving outcomes: focus on workplace issues.

PURPOSE OF REVIEW: Staff satisfaction has not traditionally been included as an intensive care unit quality indicator. The process of providing intensive care may profoundly affect clinicians. Dysfunctional encounters with coworkers and ethical burdens may extract a considerable personal toll and affect work attitudes and performance. RECENT FINDINGS: Mounting evidence indicates that psychosocial tensions, burnout and ethical stress are common and serious problems in the intensive care unit. These experiences impact negatively on job satisfaction, turnover, workplace disruption and patient care. Addressing workplace issues will help improve quality of care. SUMMARY: Two common sources of staff dissatisfaction are examined. Improving staff satisfaction can improve unit performance, and serve to attract and retain quality clinicians.

Community-acquired pneumonia: updates in assessment and management.

Community-acquired pneumonia (CAP) is a significant health condition. Knowledge of the clinical presentation and treatment of CAP are important for critical care nurses as up to 20% of patients with CAP require hospitalization and in-patient management. Patients with severe CAP requiring intensive care unit (ICU) treatment often require aggressive management including mechanical ventilation and multisystem organ support. This article presents an overview of CAP, including the presentation of typical and atypical CAP, clinical findings, and the essentials of management. Treatment differences between CAP and healthcare-acquired pneumonia and nursing implications are also highlighted.