Use of nursing care bundles for the prevention of ventilator-associated pneumonia in low-middle income countries: A scoping review.

BACKGROUND: Ventilator-associated pneumonia (VAP) is a significant concern in low-middle-income countries (LMICs), where the burden of hospital-acquired infections is high, and resources are low. Evidence-based guidelines exist for preventing VAP; however, these guidelines may not be adequately utilized in intensive care units of LMICs. AIM: This scoping review examined the literature regarding the use of nursing care bundles for VAP prevention in LMICs, to understand the knowledge, practice and compliance of nurses to these guidelines, as well as the barriers preventing the implementation of these guidelines. STUDY DESIGN: The review was conducted using Arksey and O'Malley's (2005) five-stage framework and the PRISMA-ScR guidelines guided reporting. Searches were performed across six databases: CINAHL, Medline, Embase, Global Health, Scopus and Cochrane, resulting in 401 studies. RESULTS: After screening all studies against the eligibility criteria, 21 studies were included in the data extraction stage of the review. Across the studies, the knowledge and compliance of nurses regarding VAP prevention were reported as low to moderate. Several factors, ranging from insufficient knowledge to a lack of adequate guidelines for VAP management, served as contributing factors. Multiple barriers prevented nurses from adhering to VAP guidelines effectively, including a lack of audit/surveillance, absence of infection prevention and control (IPC) teams and inadequate training opportunities. CONCLUSIONS: This review highlights the need for adequate quality improvement procedures and more efforts to conduct and translate research into practice in intensive care units in LMIC. RELEVANCE TO CLINICAL PRACTICE: IPC practices are vital to protect vulnerable patients in intensive care units from developing infections and complications that worsen their prognosis. Critical care nurses should be trained and reinforced to practice effective bundle care to prevent VAP.

Implementing integrative therapies in adult critical care: Barriers and strategies.

BACKGROUND: Critically ill patients experience intense physical and psychological stressors in the intensive care unit (ICU). More than half of ICU survivors report overwhelming mental health symptoms after ICU discharge, such as post-traumatic stress symptoms, anxiety, and depression. Relaxation-inducing integrative therapies such as guided imagery, massage, therapeutic touch, music therapy, and spirituality-based healing practices have the potential to promote comfort and relaxation and improve patient outcomes. OBJECTIVES: The aim of this study was to explore the attitudes of healthcare professionals towards the implementation of relaxation-inducing integrative therapies in critical care, barriers to implementation, and potential strategies to overcome them. METHODS: We conducted seven focus group interviews with 23 critical care clinicians (70% nurses, 17% allied health professionals, 13% physicians). Interviews were audiotaped and transcribed verbatim. Data were thematically analysed using an inductive content analysis approach. FINDINGS: Results reveal a constant interplay between mostly positive personal attitudes towards implementation of integrative therapies and the perceived culture and priorities of the unit. The main benefits for critically ill patients as perceived by participants were promotion of comfort, sleep, and coping, increase of trust, and decrease of pain and stress. As for barriers, dominant themes were a perceived lack of evidence, cost, and time constraints and the fear of loss of professional credibility. Participants related nurses' education and training, family involvement, and leadership were seen as main strategies for implementation. CONCLUSIONS: The dominant ICU culture needs to be considered when implementing integrative therapies. Education, access to evidence, and role modelling are proposed as means to shift the ICU culture towards utilisation of integrative therapies in critical care.

Screening tools for post-intensive care syndrome and post-traumatic symptoms in intensive care unit survivors: A scoping review.

BACKGROUND: Evidence suggests that intensive care unit (ICU) survivors often suffer long-term complications such as post-intensive care syndrome (PICS) and post-traumatic stress disorder (PTSD) from critical illness and ICU stay. PICS and PTSD affect both ICU survivors and their families, which overburdens the healthcare systems. Lack of evidence on the comparative psychometric properties of assessment tools is a major barrier in evidence-based screening for post-ICU symptomatology and health-related quality of life. OBJECTIVES: We aimed to identify existing tools for screening PTSD and PICS in ICU survivors and their families and to examine evidence on the validity, reliability, sensitivity, and specificity of existing tools, as reflected in published peer-reviewed studies. METHOD: A scoping review based on literature searches (CINAHL, MEDLINE, EMBASE, PsycINFO, Scopus, Health and Psychosocial Instruments, Dissertations and Theses Global, and Google Scholar) and predefined eligibility criteria was conducted according to current scoping review guidelines. FINDINGS: We identified 44 studies reporting on the development and assessment of psychometric properties of PICS/PTSD in ICU survivors or families globally. We identified five tools addressing all three aspects of PICS manifestations, one tool for both physical and mental aspects of PICS, and fivefive tools for quality-of-life assessment in ICU survivors. Altogether, 25 tools assess only one aspect of PICS: five for cognitive impairment, seven for physical impairment, and 13 for mental health impairment and PTSD in ICU survivors. However, only two tools were found for PICS-family assessment. Other findings include (i) unclear validity and often limited feasibility of tools, (ii) low diagnostic accuracy of cognitive assessment tools, and (iii) evidence of appropriate psychometric properties and feasibility of psychological health assessment tools. CONCLUSION: These results have implications for the selection and implementation of the assessment methods as a means for promoting meaningful patient-centred clinical outcomes to minimise long-term sequelae, reduce the rate of rehospitalisation, and optimise recovery after ICU discharge.

Device-associated health care-associated infections: The effectiveness of a 3-year prevention and control program in the Republic of Cyprus.

BACKGROUND: Device-associated health care-associated infections (DA-HAIs) are a major threat to patient safety, particularly in the Intensive Care Unit (ICU). This study aimed to evaluate the effectiveness of a bundle of infection control measures to reduce DA-HAIs in the ICU of a General Hospital in the Republic of Cyprus, over a 3-year period. METHODS: We studied 599 ICU patients with a length of stay (LOS) for at least 48 hours. Our prospective cohort study was divided into three surveillance phases. Ventilator-associated pneumonia (VAP), central line-associated blood-stream infections (CLABSI), and catheter-associated blood-stream infections (CAUTI) incidence rates, LOS, and mortality were calculated before, during, and after the infection prevention and control programme. RESULTS: There was a statistically significant reduction in the number of DA-HAI events during the surveillance periods, associated with DA-HAIs prevention efforts. In 2015 (prior to programme implementation), the baseline DA-HAIs instances were 43: 16 VAP (10.1/1000 Device Days), 21 (15.9/1000DD) CLABSIs, and 6 (2.66/1000DD) CAUTIs, (n = 198). During the second phase (2016), CLABSIs prevention measures were implemented and the number of infections were 24: 14 VAP (12.21/1000DD), 4 (4.2/1000DD) CLABSIs, and 6 (3.22/1000DD) CAUTIs, (n = 184). During the third phase (2017), VAP and CAUTI prevention measures were again implemented and the rates were 6: (3 VAP: 12.21/1000DD), 2 (1.95/1000DD) CLABSIs, and 1 (0.41/1000DD) CAUTIs, (n = 217). There was an overall reduction of 87% in the total number of DA-HAIs instances for the period 1 January 2015 to 31 December 2017. CONCLUSIONS: The significant overall reduction in DA-HAI rates indicates that a comprehensive infection control programme can affect DA-HAI rates.

Critical care nursing service costs: Comparison of the top-down versus bottom-up micro-costing approach in Brazil.

AIM: To estimate the nursing service costs using a top-down micro-costing approach and to compare it with a bottom-up micro-costing approach. BACKGROUND: Accurate data of nursing cost can contribute to reliable resource management. METHOD: We employed a retrospective cohort design in an adult intensive care unit in São Paulo. A total of 286 patient records were included. Micro-costing analysis was conducted in two stages: a top-down approach, whereby nursing costs were allocated to patients through apportionment, and a bottom-up approach, considering actual nursing care hours estimated by the Nursing Activities Score (NAS). RESULTS: The total mean cost by the top-down approach was US$1,640.4 ± 1,484.2/patient. The bottom-up approach based on a total mean NAS of 833 ± 776 points (equivalent to 200 ± 86 hr of nursing care) yielded a mean cost of US$1,487.2 ± 1,385.7/patient. In the 268 patients for whom the top-down approach estimated higher costs than the bottom-up approach, the total cost discrepancy was US$4,427.3, while for those costed higher based on NAS, the total discrepancy was US$436.9. The top-down methodology overestimated costs for patients requiring lower intensity of care, while it underestimated costs for patients requiring higher intensity of care (NAS >100). CONCLUSIONS: The top-down approach may yield higher estimated ICU costs compared with a NAS-based bottom-up approach. IMPLICATIONS FOR NURSING MANAGEMENT: These findings can contribute to an evidence-based approach to budgeting through reliable costing methods based on actual nursing workload, and to efficient resource allocation and cost management.

Pilot exploration of post-traumatic stress symptoms in intensive care unit survivors in Cyprus.

BACKGROUND: Approximately, 20% of intensive care unit (ICU) survivors develop post-traumatic stress disorder (PTSD) symptoms. Although Davidson Trauma Scale (DTS) provides a comprehensive approach to PSTD symptoms, there is no evidence on DTS-I-M use in ICU survivors. AIMS AND OBJECTIVES: To validate the modified intensity Davidson Trauma Scale (DTS-I-M) (wherein the frequency and severity subscales are combined to express symptoms intensity) in a convenience sample of ICU survivors in Cyprus, and to explore the prevalence of PTSD symptoms and related predictors. DESIGN: An instrument validation design, along with a cross-sectional, correlational study design was employed. METHODS: Translation and cultural adaptation of the instrument were achieved through a group of experts and pilot testing. The DTS-I-M was administered via telephone. Participants' clinical data (length of ICU stay [LOS], mechanical ventilation duration [MVD], admission diagnosis, medication history) and demographics (age, gender) were collected. Non-parametric comparisons, and regression analyses to identify predictors of DTS-I-M scores and PTSD symptoms were employed. RESULTS: The Cypriot DTS-I-M version demonstrated high test-retest (Pearson's r = 0.928, P < .001) and internal consistency (Cronbach's [α] alpha = .97) reliability in a sample of 69 ICU survivors (62.7% response). About 36.2% of participants reported PTSD symptoms. Factor analysis confirmed the construct validity of the DTS-I-M, and a 3-factor structure (encompassing intrusive, avoidance, hyperarousal, mood, and cognitive symptoms). In a multiple regression, MVD (B = -3.11, OR [95% CI] = 22.58 [3.07-166.09, P = .002]) and LOS (r2 = 0.302, P = .002) were statistically significant predictors of DTS-I-M score. CONCLUSION: We confirm the applicability of the DTS-I-M for the assessment of PTSD symptoms in ICU survivors; and offer preliminary evidence on the prevalence and predictors of post-ICU PTSD symptoms in Cyprus. RELEVANCE TO CLINICAL PRACTICE: DTS-I-M is an appropriate screening tool for PTSD symptoms after ICU hospitalization. Patients with longer MVD and LOS are at higher risk for post-ICU PTSD symptoms and seem to experience more intense relevant symptoms.

Effectiveness of cognitive interventions on cognitive outcomes of adult intensive care unit survivors: A scoping review.

BACKGROUND: Cognitive impairments have been identified as significant under-recognised negative sequelae of postintensive care syndrome. No treatment guidelines exist for cognitive interventions addressing the devastating consequences of impairments and their potential impact on outcomes of intensive care unit (ICU) survivors. AIM: The aim of the study was to identify all available cognitive interventions and measurable outcomes for the cognitive rehabilitation of adult ICU survivors, as reported in published articles. Secondary aims included to critically synthesise existing evidence in improving adult ICU survivors' cognitive outcomes after ICU discharge and to extract implications for future research. METHODS: A scoping review was conducted based on a rigorous literature search (CINAHL, Embase, MEDLINE, PubMed, SCOPUS, Cochrane Library, and Google Scholar) using predefined keywords. The protocol was based on current guidelines. Eligibility criteria included published (i) experimental and quasi-experimental studies reporting the effects of cognitive interventions on cognitive outcomes of adult critical illness survivors after hospital discharge and (ii) protocols identifying cognitive interventions with predefined cognitive outcome measures. RESULTS: Seven studies were included: three experimental studies, two quasi-experimental studies, and two published protocols. Significant heterogeneity in the type of interventions, outcome measures, and assessment tools was noted. Interventions included variations of goal management training and an integrated multidisciplinary model. The setting, delivery, and duration of interventions varied. Cognitive outcomes included variations of global cognitive function and executive function. Overall, the evidence on the effects of cognitive interventions, as compared with routine care, in improving global cognitive function is inconclusive. More evidence support exists with respect to improving executive function. CONCLUSION: Although various cognitive intervention approaches have shown some positive effects on outcomes of ICU survivors after hospital discharge, the high risk of bias and high heterogeneity across studies preclude conclusions about the most appropriate post-ICU care to rehabilitate cognitive deficits in critical care survivors. This review highlighted a number of methodological limitations that require further investigation.

Tools for assessment of acute psychological distress in critical illness: A scoping review.

OBJECTIVES: Patients' experience of psychological distress in the intensive care unit (ICU) is associated with adverse effects, reduced satisfaction, and delayed physical and psychological recovery. There are no specific guidelines for the assessment and management of acute psychological distress during hospitalisation in the ICU. We reviewed existing tools for the assessment of acute psychological distress in ICU patients, examined evidence on their metric properties, and identified potential gaps and methodological considerations. METHOD: A scoping review based on literature searches (Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, PsycINFO, Scopus, Health and Psychosocial Instruments, Dissertations and Theses Global, and Google Scholar) and predefined eligibility criteria was conducted as per current scoping review guidelines. FINDINGS: Overall, 14 assessment tools were identified having been developed in diverse ICU settings. The identified tools assess mainly anxiety and depressive symptoms and ICU stressors, and investigators have reported various validity and reliability metrics. It was unclear whether available tools can be used in specific groups, such as noncommunicative patients and patients with delirium, brain trauma, stroke, sedation, and cognitive impairments. CONCLUSION: Available tools have methodological limitations worth considering in future investigations. Given the high prevalence of psychiatric morbidity in ICU survivors, rigorously exploring the metric integrity of available tools used for anxiety, depressive, and psychological distress symptom assessment in the vulnerable ICU population is a practice and research priority. RELEVANCE TO CLINICAL PRACTICE: These results have implications for the selection and implementation of psychological distress assessment methods as a means for promoting meaningful patient-centred clinical outcomes and humanising ICU care experiences.

Validation of the Greek Version of Comfort-B, FLACC, and BPS Scales in Critically Ill Children and Their Association with Clinical Severity.

BACKGROUND: A variety of valid pediatric pain assessment tools are used in clinical practice globally; however, none have been validated for use in the Pediatric Intensive Care Unit (PICU) in Greece. Furthermore, the association between pain behavioral responses and clinical status is unclear. AIMS: To assess the reliability and validity of the Greek version of FLACC, Comfort B, and BPS pain scales in critically ill children and to explore their association with clinical severity (Denver MOF, PMODS) and levels of sedation and analgesia. METHODS: A methodological and descriptive correlational study was performed in a 6-bed PICU. A total of 60 observations in a sample of 30 children (mean age 4.1 years; 63.3% male) were obtained by 2 independent nurses during rest and painful procedures. At the same time, the bedside nurse assessed the child's pain intensity using the VASobs. RESULTS: High internal consistency and strong interrater reliability were detected (Cronbach's alpha ≥ .85; ICC > .95, p < .001). The agreement between observers was satisfactory (0.71 ≤ Kappa ≤ 0.96, p < .001). Strong correlations were found among the scales (0.65 ≤ rho ≤0 .98, p < .05). Increased pain scores (≥moderate pain) were observed during painful procedures regardless the administration of analgesia. Statistically significant correlations were found between clinical severity and the FLACC and Comfort B scores (-0.577 ≤ rho ≤ -0.384, p < .05). CONCLUSIONS: These pain tools were found to be suitable for this sample of children in Greece. Wider application of these tools in Greek PICUs and further research regarding their association with the clinical severity and the pain responses is required for the improvement of pain management in critically ill children.

Is there any association among depressive symptoms, job satisfaction and self-assessed empathy? A correlational study in Greek Psychiatric/Mental Health Nurses.

A descriptive correlational design was applied to explore association among self-assessed depressive symptoms, job satisfaction and self-assessed empathy in 206 Greek Psychiatric-Mental Health Nursing Personnel (PMHNP). Depressive symptom intensity was associated with satisfaction from performed tasks (r = -0.157, p = 0.033), professional prestige (r = -0.255, p < 0.0001), relations with colleagues (r = -0.263, p < 0.0001) and empathy (r = -0.183, p = 0.013). In a regression model, only satisfaction from relations and workload remained significant depressive symptom predictors after controlling for important covariates. The quality of relations with colleagues and workload are important predictors of PMHNPs self-perceived mental health well-being, independently of clinicians' self-assessed empathy or overall professional satisfaction.

Effects of the Enhanced Recovery Program on the Recovery and Stress Response in Patients With Cancer Undergoing Pancreatoduodenectomy.

Aim the study was the comparison of enhanced recovery after surgery (ERAS) versus conventional care (CON) protocols in patients undergoing pancreatoduodenectomy with regard to pain intensity, emotional response (optimism/sadness/stress), and stress biomarker levels (adrenocorticotropopic hormone, cortisol). We conducted a prospective two-group randomized controlled study with repeated measures in 85 patients with cancer pancreatoduodenectomy. In the ERAS group (N = 44), the ERAS protocol was followed, compared with the CON group (N = 41). We assessed pain with the numeric rating scale and a behavioral scale (Critical Care Pain Observation Tool), emotional responses (numeric rating scale), and serum adrenocorticotropopic hormone and cortisol levels at three time points: T1, admission day; T2, day of surgery; and T3, discharge day (ERAS) or the fifth day of stay (CON). Data were analyzed by linear mixed modeling to account for repeated measurements. We observed decreased postoperative pain in ERAS patients after adjusting for confounders (p = .002) and a trend for less complications. No significant associations with stress/emotional responses were noted. Only age, but not protocol, appeared to have a significant effect on adrenocorticotropopic hormone levels despite a significant interaction with time toward increased adrenocorticotropopic hormone levels in the ERAS group. In conclusion, despite its fast track nature, ERAS is not associated with increased stress in patients undergoing pancreatoduodenectomy and is associated with decreased pain.

The lived experience of delirium in intensive care unit patients: A meta-ethnography.

OBJECTIVES: The objectives were to interpretatively synthesise qualitative findings on patients' lived experience of delirium in the intensive care unit (ICU) and to identify meanings and potential existential issues that affect them during and after their experience. Patients may face existential challenges when they are vulnerable in their confusion, all while confronting the reality of their mortality in the critically ill state. REVIEW METHODS: The study involved meta-ethnographic synthesis of published qualitative studies addressing the lived experience of delirium for patients in ICU based on a systematic literature search. DATA SOURCES: MEDLINE, PsycINFO, Embase, Scopus, CINAHL, ProQuest, and Cochrane were the sources. Studies were selected based on the predefined inclusion/exclusion criteria. The identified studies were subjected to a quality appraisal based on a Critical Appraisal Skills Programme tool. RESULTS: Based on the eligibility criteria, nine qualitative studies were included, of overall medium to high quality. One core theme, "a perturbing altered reality" and four main themes were identified: "disturbed sense of time", "omnipresent feeling of fear", "impact of human connection", and "perceiving surreal events". These four themes illustrate how the three salient existential issues of uncertainty, self-perceived helplessness, and death that are present in delirium make it a highly distressing experience for patients in ICU. CONCLUSIONS: Critically ill patients who experience delirium appear to face intense existential issues, which may not be identified by care providers and may remain unaddressed during their ICU stay and after discharge. Patients report that addressing the memories of these issues would be therapeutic. Future research needs to explore care approaches to meet the unique psychosocial needs of critically ill patients with delirium.

The effectiveness of systematic pain assessment on critically ill patient outcomes: A randomised controlled trial.

BACKGROUND: Evidence suggests that critically ill patients' pain may still be underestimated. Systematic approaches to pain assessment are of paramount importance for improving patients' outcomes. OBJECTIVES: To investigate the effectiveness of a systematic approach to pain assessment on the incidence and intensity of pain and related clinical outcomes in critically ill patients. METHODS: Randomized controlled study with consecutive critically ill patients allocated to either a standard care only or a systematic pain assessment group. The Behavioral Pain Scale (BPS) and the Critical Pain Observation Tool (C-POT) were completed twice daily for all participants. In the intervention group, clinicians were notified of pain scores. Linear Mixed Models (LMM) for the longitudinal effect of the intervention were employed. RESULTS: A total of 117 patients were included (control: n=61; intervention: n2=56). The incidence of pain (C-POT >2) in the intervention group was significantly lower compared to the control group (p < .001). The intervention had a statistically significant effect on pain intensity (BPS, p = 0.01). The average total morphine equivalent dose in the intervention group was higher than in the control group (p = 0.045), as well as the average total dose of propofol (p = 0.027). There were no statistically significant differences in ICU mortality (23.4% vs 19.3%, p=0.38, odds ratio 0.82 [0.337-1.997]) and length of ICU stay (13.5, SD 11.1 vs 13.9, SD 9.5 days, p= 0.47). CONCLUSION: Systematic pain assessment may be associated with a decrease in the intensity and incidence of pain and influence the pharmacological management of pain and sedation of critically ill patients.

Effects of massage on outcomes of adult intensive care unit patients: a systematic review.

BACKGROUND: The critical care experience is particularly stressful for patients, which can result in a number of physiological and psychological consequences, including haemodynamic instability, increased pain, agitation and delirium, leading to prolonged mechanical ventilation, length of stay and subsequent complications. Massage therapy encompasses different techniques to promote relaxation and to counter stress, therefore potentially affecting several patients' outcomes. AIMS: To systematically review evidence on the effects of massage on outcomes of adult critically ill patients. The outcome measures included pain, vital signs (VS), haemodynamic measurements, level of consciousness, sleep quality, muscle tension, anxiety, feelings of calm and relaxation, coping, arterial blood gases and serum biomarkers. METHOD: This was a systematic review based on focused literature searches (PubMed, CINAHL, Scopus, EMBASE-Ovid databases, Google Scholar). The Cochrane Collaboration's tool was used to assess the risk of bias. Eligibility criteria included published experimental and quasi-experimental studies reporting on the physiological and psychological outcomes of critically ill patients. RESULTS: Based on the selection criteria, 12 studies were included in the review. The main findings are as follows: 8 of 12 studies used randomized control designs with high internal validity, and there was a high level of evidence of favourable effects with respect to improvements in VS and a reduction in pain and anxiety. Outcomes that need to be more rigorously pursued include quality of sleep, analgesic and sedative dosages and level of consciousness. CONCLUSION: The results suggest that massage interventions can have positive effects on critically ill patients' outcomes. However, there are several gaps in the literature, along with methodological limitations, that require further consideration in critical care settings. RELEVANCE TO CLINICAL PRACTICE: The results of this systematic review can inform implementation of massage interventions in critical care, which can be challenging as a result of several barriers.

A Meta-ethnography of Out-of-Hospital Cardiac Arrest Survivors' Meanings on Life and Death.

BACKGROUND: Although out-of-hospital cardiac arrest (OHCA) survivors' physiological outcomes have been addressed, less is known on the holistic needs of individuals after OHCA, which hinders our ability to prioritize care around what really matters to survivors. AIM: The aim of this study was to interpretatively synthesize qualitative findings on OHCA survivors' perceptions and meanings of life and death and existential issues. METHODS: We used a meta-ethnographic synthesis of published qualitative studies addressing the experiences of OHCA survivors based on a systematic literature search (CINAHL, PsycINFO, Scopus, PubMed). Studies were selected based on predefined inclusion/exclusion criteria. The identified studies were subjected to a quality appraisal based on the Critical Appraisal Skills Programme. RESULTS: Based on eligibility criteria, 6 phenomenological studies were included, of overall medium to high quality. One core theme, "the reality of death," and 4 main themes were identified: "redefining existence"; "revaluing death"; "being familiar with, yet oblivious of death"; and "living consciously." Emerging from the realization of death, the themes appeared to describe a gradual progression toward living consciously. CONCLUSIONS: An existential trajectory and a need for meaning are central in the experience of OHCA survivors. When existential issues are not addressed, the ongoing suffering may interfere with survivors' recovery and quality of life. Future research needs to address specific needs and ways to support survivors' meaning-making.

The effect of guided imagery on physiological and psychological outcomes of adult ICU patients: A systematic literature review and methodological implications.

OBJECTIVES: Guided imagery (GI) is a relaxation technique that is being increasingly explored in various patients' populations. We systematically reviewed evidence on the effects of GI on physiological and psychological outcomes of adult critically ill patients and extracted implications for future research. REVIEW METHOD USED: Systematic literature review of published studies based on the Cochrane Guidelines. DATA SOURCES: Studies were located through literature searches of CINAHL, PubMed, Embase, Cochrane Database of Systematic Reviews and Psych-Info. REVIEW METHODS: We explored effects of GI in critically illness. The outcome measures included pain, anxiety, hemodynamic measurements, stress neuropeptides, length of stay, sleep quality, inflammatory markers, patient satisfaction and cost of care. The Cochrane Collaboration's tool for assessing risk of bias was employed. Extracted data included pathophysiological framework, sample, diagnoses of participants, specifics of intervention, design, experimental groups, analyses and main outcomes. RESULTS: Based on the selection criteria, 10 studies were identified, involving N=1391 critically ill patients. The main limitations include incomplete outcome data and selective reporting, incomplete blinding and lack of experimental group allocation concealment. Due to heterogeneity and incomplete reporting, a meta-analysis was not feasible. Our findings included: (a) favourable effects of the intervention with regard to decrease of pain, anxiety and LOS; (b) many studies employing randomised controlled trial designs; (c) a predominant focus on patients with cardiac surgery; (d) large heterogeneity in measurement of outcomes. Moreover, the evidence suggests that improvements in sleep quality, patient satisfaction and cost of care merit further investigation. Methodological implications include the need to clarify the underlying physiological framework, the use of repeated measure designs and the adjustment for confounders. CONCLUSIONS: On the basis of these results, and of the absence of reported side-effects, we conclude that GI is a promising patient-centered approach for the improvement of a number of patients' outcomes that merits further investigation in critical care.

Surveillance of device associated infections and mortality in a major intensive care unit in the Republic of Cyprus.

BACKGROUND: Device-associated health care-associated infections (DA-HAI) pose a threat to patient safety, particularly in the intensive care unit. The aim of this study was to assess the incidence of DA-HAIs, mortality and crude excess mortality at a General Hospital's Intensive Care Unit (ICU) in the Republic of Cyprus for 1 year period. METHODS: A prospective cohort, active DA-HAIs surveillance study with the use of Health Acquired Infections (HAIs) ICU Protocol (v1.01 standard edition) as provided by ECDC/NHSN for the active DA-HAIs surveillance study was conducted. The study sample included 198 ICU patients admitted during the research period and hospitalized for over 48 h. The Ventilator-Associated Pneumonia (VAP), Central Line-Associated Bloodstream Infection (CLABSI), and Catheter-Associated Urinary Tract Infection (CAUTI) rates, length of stay (LOS), mortality, and crude excess mortality were calculated. RESULTS: CLABSI was the most frequent DA-HAI with 15.9 incidence rate per 1000 Central Venus Catheter (CVC) days. The VAP rate, was 10.1 per 1000 ventilator days and the CAUTI rate was 2.7 per 1000 urinary catheter days. Device associated infections were found to be significantly associated with the length of ICU stay (p < 0.001), the CVC days (p < 0.001), ventilator days (p < 0.001), and urinary catheter days (p < 0.001). The excess mortality was 22.1% for those who acquired a DA-HAI (95% CI, 2-42.2%) compared to the patients who remained DA-HAI free. Mortality of patients with VAP infection was 2.3 times higher (RR = 2.33 95% CI, 1.07-5.05) than those patients admitted without a HAI and subsequently did not acquire a DA-HAI. The most frequently isolated pathogen was Staphylococcus epidermidis (13.9%) and Candida albicans (13.9%). CONCLUSIONS: Higher DA-HAIs rates and device utilization than the international benchmarks were found in this study, calling into question the safety of preventative practices employed in this unit.

Nurse-physician collaboration and associations with perceived autonomy in Cypriot critical care nurses.

BACKGROUND AND AIMS: Increased nurse-physician collaboration is a factor in improved patient outcomes. Limited autonomy of nurses has been proposed as a barrier to collaboration. This study aims to explore nurse-physician collaboration and potential associations with nurses' autonomy and pertinent nurses' characteristics in adult intensive care units (ICUs) in Cyprus. DESIGN AND METHODS: Descriptive correlational study with sampling of the entire adult ICU nurses' population in Cyprus (five ICUs in four public hospitals, n = 163, response rate 88·58%). Nurse-physician collaboration was assessed by the Collaboration and Satisfaction About Care Decisions Scale (CSACD), and autonomy by the Varjus et al. scale. RESULTS: The average CSACD score was 36·36 ± 13·30 (range: 7-70), implying low levels of collaboration and satisfaction with care decisions. Male participants reported significantly lower CSACD scores (t = 2·056, p = 0·04). CSACD correlated positively with years of ICU nursing experience (r = 0·332, p < 0·0001) and professional satisfaction (r = 0·455, p < 0·0001). The mean autonomy score was 76·15 ± 16·84 (range: 18-108). Higher degree of perceived collaboration (CSACD scores) associated with higher autonomy scores (r = 0·508, p <0·0001). CONCLUSIONS: Our findings imply low levels of nurse-physician collaboration and satisfaction with care decisions and moderate levels of autonomy in ICU nurses in Cyprus. RELEVANCE TO CLINICAL PRACTICE: The results provide insight into the association between nurse-physician collaboration and nurses' autonomy and the correlating factors.

Systematic review of gender- dependent outcomes in sepsis.

BACKGROUND: Men and women appear to exhibit different susceptibilities to sepsis and possibly divergent outcomes. However, the effect of sex and gender in critical illness outcomes is still controversial and the underlying mechanisms appear to be complex. OBJECTIVES: We aimed to systematically review and synthesize evidence on the influence of sex on outcomes in critically ill adult patients with sepsis, as reported in published studies specifically including investigation of the effect of sex among their aims. Primary outcome measures include in-hospital mortality, intensive care unit (ICU) mortality and length of stay (LOS) in the ICU. SEARCH STRATEGY: The review was based on focused literature searches (CINAHL, PUBMED, EMBASE and COCHRANE). Methodological quality was assessed through the STROBE checklist and the Cochrane Tool for Bias in Cohort Studies. Meta-analysis was performed using STATA. Published observational studies addressing outcomes of sepsis among their primary aims and having included gender comparisons among primary outcomes in critically ill adult patients were included. RESULTS: A total of eight eligible studies were included. With the exception of mortality, it was not possible to perform meta-analysis for other outcomes. Included studies reported data on 25,619 patients with sepsis (14 309 male/11 310 female). There is a paucity of well-designed studies addressing the effect of sex on mortality among patients with sepsis, and absence of studies addressing the effects of sex on multiple organ dysfunction of non-infectious origin. There was significant heterogeneity among study estimates (p = 0·001; I2 =78·1%). CONCLUSIONS: Although results of data syntheses appear to point towards a small disadvantage for survival among women, our results suggest that data on the impact of sex on sepsis outcomes remain equivocal. Implications for future research include approaches to adjustment for confounders and prospective designs. RELEVANCE TO CLINICAL PRACTICE: Clarifying sex-related differences in sepsis, if any, is crucial for informing evidence-based care.

Perceptions of critical and emergency department nurses regarding changes in their professional role.

Objective Preliminary investigation of the way Greek critical and emergency department nurses conceptualize changes in their professional role. Method A qualitative focus-group methodology was applied. Following purposeful sampling and informed consent of participants. Results Participated eight individuals. The need for enhancement of nurses' participation in decision-making in order for an actual change in their professional role to be achieved was the central theme of participants' narratives. Perceived advancements in professional role performance regarded: evidence-based practice; technology; education, knowledge; clinical skills; research; heightened nurse-physician collaboration. Perceived reasons why these advancements failed to enhance nurses' professional role were lack of meritocracy; competitive relationships; lack of support among nurses; insufficient managerial support; budget limitations. Conclusion Despite advancements in clinical practice, participants did not deem that their professional role was enhanced significantly, as participation in decision-making and control over practice remain limited. Interventions targeted to enhance nurses' participation in clinical decision-making, and overall professional autonomy are recommended.