Pressure Injuries in Critical Care Patients: A Conceptual Schema.

GENERAL PURPOSE: To outline a conceptual schema describing the relationships among the empirically supported risk factors, the etiologic factors, and the mitigating measures that influence pressure injury (PI) development in the critical care population. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will: 1. Choose a static intrinsic factor that increases the risk for the development of PI. 2. List several dynamic intrinsic risk factors for developing a PI. 3. Identify dynamic extrinsic risk factors that may predispose a patient to developing a PI. 4. Explain the pathophysiology of PI development.

The first step in successful pressure injury (PI) prevention is to determine appropriate risk factors. In patients who are critically ill, PI risk is multietiologic, including the pathophysiologic impacts associated with a critical illness, concomitant preexisting comorbid conditions, and treatment-related factors that are essential in the ongoing management of a critical illness. To outline a conceptual schema describing the relationships among the empirically supported risk factors, the etiologic factors, and the mitigating measures that influence PI development in the critical care population. Risk factors for PI included in the conceptual schema were identified after a comprehensive review of the literature. Risk factors were categorized as static intrinsic factors, dynamic intrinsic factors, or dynamic extrinsic factors. The schema illustrates the complex relationships between risk factor duration and intensity and the underlying etiology of PI development. The relationships among cumulative risk factors, etiologic factors, and mitigating measures for PI prevention are also outlined in the schema within the context of potentially unavoidable PI development. Examining PI development in patients who are critically ill through the lens of a conceptual schema may guide future research endeavors focusing on the etiologic bases for PI development. It may also provide a framework to explore alternatives to current formal PI risk assessment in this unique subset of hospitalized patients.

The Use of Physical Therapy ICU Assessments to Predict Discharge Home.

OBJECTIVES: To establish cutoff values for making recommendations for discharge to the home setting using standardized physical therapy assessments. DESIGN: Retrospective study. SETTING: Five ICUs at a large academic medical center. PATIENTS: 1,203 ICU patients. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The Functional Status Score for the ICU and the ICU Mobility Scale were collected during the initial physical therapy assessment, at ICU discharge, and prior to hospital discharge. The Activity Measure for Post-Acute Care-Inpatient Mobility Short Form "6 clicks" was only collected during the initial physical therapy assessment. Receiver Operating Characteristic curves were used to determine a potential cutoff value for discharge home. The Receiver Operating Characteristic was adjusted for ICU and hospital length of stay along with mobility status prior to hospital admission. Cutoff values were then determined by using Youden's Index. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated based on these cut off values. The Functional Status Score for the ICU at ICU discharge was the best predictor of a discharge to the home setting in patients who had an ICU admission. The area under the curve for the Functional Status Score for the ICU at ICU discharge was 0.80. A Functional Status Score for the ICU score at ICU discharge of 19 or higher predicted discharge to home with a sensitivity of 82.9% and specificity of 73.6% CONCLUSIONS:: The Functional Status Score for the ICU at ICU discharge provided the best accuracy for making a timely recommendation for discharge home in patients who had an ICU admission.

Improving Caregivers' Perceptions Regarding Patient Goals of Care/End-of-Life Issues for the Multidisciplinary Critical Care Team.

OBJECTIVE: With population aging and growth, use of critical care medicine at the end of life continues to rise, while many critical care providers are not adequately trained regarding goals of care/end-of-life (GOC/EOL) issues. A multidisciplinary intensive care unit (ICU) team intervention regarding GOC/EOL communication will enhance the clinical abilities of all critical care providers when discussing GOC/EOL issues and increase ICU staff comfort level while improving transitions for patients to a comfort care approach. DESIGN: This study was a preintervention/postintervention survey evaluation. SETTING: This study was conducted at an academic tertiary surgical burn trauma ICU. POPULATION: The intervention was provided to nursing, ancillary staff, house staff, and attending physicians. INTERVENTION: An initial survey was circulated among the critical care staff for baseline expectations, satisfaction, and understanding of GOC/EOL care. A robust intervention was begun including the creation of a multidisciplinary GOC/EOL team, communication tools for providers, patient-family pamphlets, standardized EOL order sets, and formalized didactic sessions. Subsequently, the same survey was circulated and compared to baseline data. MEASUREMENTS: Preintervention/postintervention survey data were reviewed and statistically analyzed. MAIN RESULTS: Our survey response rate for preintervention/postintervention was 50.4% and 36.1%, respectively. The intervention generated heightened interest in improving family communication and provided focal direction to foster this growth. Based on the serial surveys regarding our intervention, statistically significant staff improvements were seen in "work stress" (P = .04), "EOL information" (P = .006), and "space allotment" (P = .001). Improved congruence of families and health care providers regarding decision over intensity of care was also noted. CONCLUSION: We created a novel unit-based multidisciplinary program for improved EOL/GOC approaches in the critical care setting. A similarly formatted program could be adapted by other ICUs. Benefits of such a program include improving caregivers' perceptions regarding EOL/GOC issues and fostering critical care team growth.

A Novel ICU Hand-Over Tool: The Glass Door of the Patient Room.

BACKGROUND: Poor communication among health-care providers is cited as the most common cause of sentinel events involving patients. Patient care in the critical care setting is incredibly complex. A consistent care plan is necessary between day/night shift teams and among bedside intensive care unit (ICU) nurses, consultants, and physicians. Our goal was to create a novel, easily accessible communication device to improve ICU patient care. METHODS: This communication improvement project was done at an academic tertiary surgical/trauma/mixed 36-bed ICU with an average of 214 admissions per month. We created a glass door template embossed on the glass that included 3 columns for daily goals to be written: "day team," "night team," and "surgery/consultant team." Assigned areas for tracking "lines," "antibiotics," "ventilator weaning," and "Deep vein thrombosis (DVT) screening" were included. These doors are filled out/updated throughout the day by all of the ICU providers. All services can review current plans/active issues while evaluating the patient at the bedside. Patient-identifying data are not included. We retrospectively reviewed all ICU safety reported events over a 4-year period (2 years prior/2 years after glass door implementation) for specific handover communication-related errors and compared the 2 cohorts. RESULTS: Information on the glass doors is entered daily on rounds by all services. Prior to implementation, 7.96% of reported errors were related to patient handover communication errors. The post glass-door era had 4.26% of reported errors related to patient handover communication errors with a relative risk reduction of 46.5%. Due to its usefulness, this method of communication was quickly adopted by the other critical care services (cardiothoracic, medical, neurology/neurosurgery, cardiology) at our institution and is now used for over 150 ICU beds. CONCLUSIONS: Our glass door patient handover tool is an easily adaptable intervention that has improved communication leading to an overall decrease in the number of handover communication errors.

Changes in Interprofessional Practice During the COVID-19 Pandemic and the Effect on Patient Outcomes: A Retrospective Observational Study.

BACKGROUND: Changes in healthcare delivery were required during the first year of the COVID-19 pandemic. OBJECTIVE: The purpose of this study was to determine the impact of the approach to care of the COVID-19 patient on nursing sensitive indicators and nutrition therapy and the utilization of rehabilitation services during the first year of the pandemic in the acute care setting. METHOD: A retrospective study of 894 patients admitted with a COVID-19 diagnosis was conducted between March 2020 and February 2021 in 3-month cohorts. All charts were reviewed for general demographics and hospital data, nursing quality indicators, and nutritional and rehabilitation services for the first 30 days of admission. RESULTS: Differences in patient characteristics were noted among the cohorts. Variations were observed between time points in hospital-acquired pressure injury occurrence, with mechanical ventilation and proning being independent predictors of hospital-acquired pressure injuries. There were differences noted in the percentage of patients with a central line-associated bloodstream infection among the time points (P < .001), but there were no differences noted in catheter-associated urinary tract infections (P = .20). Overall, 15.5% had a malnutrition diagnosis, with most patients receiving 50% of prescribed calorie and protein needs. Rehabilitation services increased over time with these services being initiated earlier in the later cohorts (P < .001). DISCUSSION: The results of this study demonstrated the impact of the pandemic on outcomes in the areas of nursing, nutrition, and rehabilitation, which varied across quarterly cohorts as we learned and developed new practices and adapted to a novel pandemic.

Original Research: Patient Perception of Fall Risk in the Acute Care Setting.

PURPOSE: Hospitals are implementing a variety of fall prevention programs to reduce the fall rates of hospitalized patients. But if patients don't perceive themselves to be at risk for falling and don't adhere to fall prevention strategies, such programs are likely to be less effective. The purpose of this study was to describe the perceptions of fall risk among hospitalized patients across four acute care specialty services. METHODS: One hundred patients who had been admitted to the study hospital and who had a Morse Fall Scale score over 45 were asked to complete the Patient Perception Questionnaire, a tool designed to explore a patient's confidence regarding their fall risk, fear of falling, and intention to engage in fall prevention activities. Morse Fall Scale scores were collected via retrospective chart review. Data were analyzed using descriptive statistics, Pearson correlation coefficients, and independent sample t tests. RESULTS: Participants' mean age was 65 years; 52% were male, 48% female. Although all 100 participants were deemed at risk for falls per their Morse Fall Scale scores, only 55% considered themselves to be at such risk. As patients' confidence in their ability to perform mobility tasks increased, their intention to ask for help and fear of falling significantly decreased. Patients who had been admitted as the result of a fall demonstrated significantly lower confidence scores and higher fear scores. CONCLUSIONS: Patients who score high on fall risk assessments often don't perceive themselves to be at high risk for falling, and thus might not engage in fall prevention activities. Developing a fall risk assessment method that incorporates both a patient's physiological condition and their perception of their fall risk could help reduce fall rates in the acute care setting.

Heparin or 0.9% sodium chloride to maintain central venous catheter patency: a randomized trial.

OBJECTIVE: To compare heparin (3 mL, 10 units/mL) and 0.9% sodium chloride (NaCl, 10 mL) flush solutions with respect to central venous catheter lumen patency. DESIGN: Single-center, randomized, open label trial. SETTING: Medical intensive care unit and Surgical/Burn/Trauma intensive care unit at Barnes-Jewish Hospital, St. Louis, MO. PATIENTS: Three hundred forty-one patients with multilumen central venous catheters. Patients with at least one lumen with a minimum of two flushes were included in the analysis. INTERVENTIONS: Patients were randomly assigned within 12 hrs of central venous catheter insertion to receive either heparin or 0.9% sodium chloride flush. MEASUREMENTS AND MAIN RESULTS: The primary outcome was lumen nonpatency. Secondary outcomes included the rates of loss of blood return, inability to infuse or flush through the lumen (flush failure), heparin-induced thrombocytopenia, and catheter-related blood stream infection. Assessment for patency was performed every 8 hrs in lumens without continuous infusions for the duration of catheter placement or discharge from intensive care unit. Three hundred twenty-six central venous catheters were studied yielding 709 lumens for analysis. The nonpatency rate was 3.8% in the heparin group (n = 314) and 6.3% in the 0.9% sodium chloride group (n = 395) (relative risk 1.66, 95% confidence interval 0.86-3.22, p = .136). The Kaplan-Meier analysis for time to first patency loss was not significantly different (log rank = 0.093) between groups. The rates of loss of blood return and flush failure were similar between the heparin and 0.9% sodium chloride groups. Pressure-injectable central venous catheters had significantly greater rates of nonpatency (10.6% vs. 4.3%, p = .001) and loss of blood return (37.0% vs. 18.8%, p <.001) compared to nonpressure-injectable catheters. The frequencies of heparin-induced thrombocytopenia and catheter-related blood stream infection were similar between groups. CONCLUSION: 0.9% sodium chloride and heparin flushing solutions have similar rates of lumen nonpatency. Given potential safety concerns with the use of heparin, 0.9% sodium chloride may be the preferred flushing solution for short-term use central venous catheter maintenance.

One Year Post-Discharge Outcomes After Implementation of an ICU Early Mobility Protocol.

BACKGROUND: Early mobility benefits include improved strength, decreased length of stay (LOS), and delirium. The impact of an early mobility protocol on return to activities of daily living (ADL) is less studied. OBJECTIVE: The aim of this study was to examine 1-year outcomes including ADL performance after the institution of an ICU early mobility protocol. METHODS: One year after the initiation of an early mobility protocol in 7 intensive care units (ICUs) at an academic medical center, patients with an ICU stay of 7 days or more were enrolled in a 1-year follow-up phone call study. Baseline demographic data included the following: average ICU mobility and highest ICU mobility level achieved (4 levels), highest ICU mobility score (10 levels) at ICU admission, ICU discharge (DC), hospital DC, LOS, and delirium positive days. At 4 time points after DC (1, 3, 6, 12 months), patients were contacted regarding current residence, employment, readmissions, and current level of ADL from the Katz ADL (scored 0-6) and Lawton instrumental ADL scales (scored 0-8). RESULTS: A convenience sample of 106 patients was enrolled with a mean age of 58 ± 15.4 years, ICU LOS of 18 ± 11.5 days, and hospital LOS of 37.5 ± 31 days; 58 (55%) were male; 4 expired before DC. Mobility results included mean mobility level of 1.6 ± 0.8, mean highest mobility level 3.3 ± 0.9; ICU mobility score was 5.9 ± 2.4 at time of ICU DC and 7.3 ± 2.5 at hospital DC. Katz ADL scores improved from 4.8 at 1 month to 5.6 at 12 months (P = .002), and Lawton IADL scores improved from 4.2 to 6.6 (P < .001). Mobility scores were predictors of 1 month Katz (P = .004) and Lawton (P < .001) scores. None of the mobility levels or scores were predictive for readmissions. Most patients were not working before admission, and not all returned to work. Days positive for delirium were predictive of 1 month Katz and Lawton (P = .014, .002) scores. Impact of delirium was gone by 1 year. DISCUSSION: In this critically ill patient population followed for 1 year, ICU mobility positively impacted return to ADLs and improved ADLs over time but not readmissions. Delirium positive days decreased ADL scores, but the effect diminished over time.

Identifying Risk Factors for Pressure Injury in Adult Critical Care Patients.

BACKGROUND: Critically ill patients have a variety of unique risk factors for pressure injury. Identification of these risk factors is essential to prevent pressure injury in this population. OBJECTIVE: To identify factors predicting the development of pressure injury in critical care patients using a large data set from the PhysioNet MIMIC-III (Medical Information Mart for Intensive Care) clinical database. METHODS: Data for 1460 patients were extracted from the database. Variables that were significant in bivariate analyses were used in a final logistic regression model. A final set of significant variables from the logistic regression was used to develop a decision tree model. RESULTS: In regression analysis, cardiovascular disease, peripheral vascular disease, pneumonia or influenza, cardiovascular surgery, hemodialysis, norepinephrine administration, hypotension, septic shock, moderate to severe malnutrition, sex, age, and Braden Scale score on admission to the intensive care unit were all predictive of pressure injury. Decision tree analysis revealed that patients who received norepinephrine, were older than 65 years, had a length of stay of 10 days or less, and had a Braden Scale score of 15 or less had a 63.6% risk of pressure injury. CONCLUSION: Determining pressure injury risk in critically ill patients is complex and challenging. One common pathophysiological factor is impaired tissue oxygenation and perfusion, which may be nonmodifiable. Improved risk quantification is needed and may be realized in the near future by leveraging the clinical information available in the electronic medical record through the power of predictive analytics.

Implementation of an Interdisciplinary AACN Early Mobility Protocol.

BACKGROUND: Increasing mobility in the intensive care unit is an important part of the ABCDEF bundle. Objective To examine the impact of an interdisciplinary mobility protocol in 7 specialty intensive care units that previously implemented other bundle components. METHODS: A staggered quality improvement project using the American Association of Critical-Care Nurses mobility protocol was conducted. In phase 1, data were collected on patients with intensive care unit stays of 24 hours or more for 2 months before and 2 months after protocol implementation. In phase 2, data were collected on a random sample of 20% of patients with an intensive care unit stay of 3 days or more for 2 months before and 12 months after protocol implementation. RESULTS: The study population consisted of 1266 patients before and 1420 patients after implementation in phase 1 and 258 patients before and 1681 patients after implementation in phase 2. In phase 1, the mean (SD) mobility level increased in all intensive care units, from 1.45 (1.03) before to 1.64 (1.03) after implementation (P < .001). Mean (SD) ICU Mobility Scale scores increased on initial evaluation from 4.4 (2.8) to 5.0 (2.8) (P = .01) and at intensive care unit discharge from 6.4 (2.5) to 6.8 (2.3) (P = .04). Complications occurred in 0.2% of patients mobilized. In phase 2, 84% of patients had out-of-bed activity after implementation. The time to achieve mobility levels 2 to 4 decreased (P = .05). Intensive care unit length of stay decreased significantly in both phases. CONCLUSIONS: Implementing the American Association of Critical-Care early mobility protocol in intensive care units with ABCDEF components in place can increase mobility levels, decrease length of stay, and decrease delirium with minimal complications.

Accuracy of Measuring Bladder Volumes With Ultrasound and Bladder Scanning.

BACKGROUND: Removal of urinary catheters depends on accurate noninvasive measurements of bladder volume. Patients with acute kidney injury often have low bladder volumes/ascites, possibly causing measurement inaccuracy. OBJECTIVE: To evaluate the accuracy of bladder volumes measured with bladder scanning and 2-dimensional ultrasound (US) compared with urinary catheterization among different types of clinicians. METHODS: Prospective correlational descriptive study of 73 adult critical care patients with low urine output receiving hemodialysis or unable to void. Bladder volumes were independently measured by (1) a physician and an advanced practice registered nurse using US, (2) an advanced practice registered nurse and a bedside nurse using bladder scanning, and (3) urinary catheterization (cath). Bland-Altman and χ2 analyses were conducted. RESULTS: Mean (SD) cath volume was 171.7 (269.7) mL (range, 0-1100 mL). Abdominal fluid was observed in 28% of patients. Bias was -1.3 mL for US vs cath and 3.3 mL for bladder scanning vs cath. For patients with abdominal fluid and cath volume less than 150 mL, decisions to not catheterize patients were accurate more often when based on US measurements (97%-100%) than when based on bladder scanning measurements (86%-89%; P = .02). In patients with cath volume of 300 mL or more, decisions to catheterize patients were accurate more often when based on bladder scanning measurements (94%-100%) than when based on horizontal US measurements (50%-56%; P = .001). CONCLUSIONS: Bladder volume can be measured accurately with bladder scanning or US, but abdominal fluid remains a confounding factor limiting accuracy of bladder scanning.

Implementation of a Standardized Patient/Family Communication Bundle.

During critical illness, active discussions about a person's preferences are linked with better patient outcomes. Our intensive care unit implemented an evidence-based standardized communication bundle that included education to providers on effective family communication, focused patient/family discussions to identify Durable Power of Attorney/surrogate decision maker and obtaining advanced directive documents, and documenting conversations in the electronic medical record and appropriately updating the patient's code status. The aim of the bundle was to increase compliance with conducting and documenting family discussions, clearly identifying and documenting surrogate decisions makers, and to improve patient/family satisfaction and caregiver satisfaction.

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.

OBJECTIVE: To determine a) if a checklist covering a diverse group of intensive care unit protocols and objectives would improve clinician consideration of these domains and b) if improved consideration would change practice patterns. DESIGN: Pre- and post observational study. SETTING: A 24-bed surgical/burn/trauma intensive care unit in a teaching hospital. PATIENTS: A total of 1399 patients admitted between June 2006 and May 2007. INTERVENTIONS: The first component of the study evaluated whether mandating verbal review of a checklist covering 14 intensive care unit best practices altered verbal consideration of these domains. Evaluation was performed using real-time bedside audits on morning rounds. The second component evaluated whether the checklist altered implementation of these domains by changing practice patterns. Evaluation was performed by analyzing data from the Project IMPACT database after patients left the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Verbal consideration of evaluable domains improved from 90.9% (530/583) to 99.7% (669/671, p < .0001) after verbal review of the checklist was mandated. Bedside consideration improved on the use of deep venous thrombosis prophylaxis (p < .05), stress ulcer prophylaxis (p < .01), oral care for ventilated patients (p < 0.01), electrolyte repletion (p < .01), initiation of physical therapy (p < .05), and documentation of restraint orders (p < .0001). Mandatory verbal review of the checklist resulted in a greater than two-fold increase in transferring patients out of the intensive care unit on telemetry (16% vs. 35%, p < .0001) and initiation of physical therapy (28% vs. 42%, p < .0001) compared with baseline practice. CONCLUSIONS: A mandatory verbal review of a checklist covering a wide range of objectives and goals at each patient's bedside is an effective method to improve both consideration and implementation of intensive care unit best practices. A bedside checklist is a simple, cost-effective method to prevent errors of omission in basic domains of intensive care unit management that might otherwise be forgotten in the setting of more urgent care requirements.

Nurses' Stress Associated with Nursing Activities and Electronic Health Records: Data Triangulation from Continuous Stress Monitoring, Perceived Workload, and a Time Motion Study.

As health IT has become overloaded with patient information, provider burnout and stress has accelerated. Studies have shown that EHR usage leads to heightened cognitive workload for nurses, and increases in cognitive workload can result in stronger feelings of exhaustion and burnout. We conducted a time motion study in an oncology division to examine the relationships between nurses' perceived workload, stress measured by blood pulse wave (BPw), and their time spent on nursing activities, and to identify stress associated with EHR use. We had a total of 33 observations from 7 nurses. We found that EHR-related stress is associated with nurses' perceived physical demand and frustration. We also found that nurses' perceived workload is a strong predictor of nurses' stress as well as how they spent time with their patients. They also experienced higher perceived mental demand, physical demand, and temporal demand when they were assigned to more patients, regardless of patient acuity. Our study presents a unique data triangulation approach from continuous stress monitoring, perceived workload, and a time motion study.

Tracheostomy protocol: experience with development and potential utility.

OBJECTIVES: To examine the feasibility and potential utility of a tracheostomy protocol based on a standardized approach to ventilator weaning. DESIGN: Prospective, observational data collection. SETTING: Academic medical center. PATIENTS: Surgical intensive care unit patients requiring mechanical ventilatory support. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Tracheostomy practice in 200 patients was analyzed in relation to spontaneous breathing trial (SBT) weaning. Decision for, and performance of, tracheostomy occurred (median [interquartile range]) 5.0 (3.75-8.0) and 7.0 (5.0-10.0) days following initiation of mechanical ventilation, respectively. Duration of mechanical ventilation was greater in tracheostomy compared with nontracheostomy patients (15.0 [11.0-19.0] vs. 6.0 [4.0-8.0], p < .001). For patients requiring ventilatory support for > or = 20 days, 100% of patients were maintained via tracheostomy. A protocol based on weaning performance, which included technical considerations, was developed. Individuals who failed preliminary weaning assessment or SBT for 3 successive days following 5 days (nonreintubated patients) or 3 days (reintubated patients) of ventilatory support met tracheostomy criteria. The protocol was implemented on a pilot basis in 125 individuals. Of the 55 (44.0%) patients undergoing tracheostomy, 25 (45.5%) did so consistent with criteria. Eighteen patients (32.7%) underwent tracheostomy before the time interval of data collection targeting weaning protocol performance, and 12 patients (21.8%) passed SBT on one or more occasions, were not extubated, and proceeded to tracheostomy. CONCLUSIONS: A standardized approach in which the decision for tracheostomy is based on objective measures of weaning performance may be a means of using this procedure more consistently and effectively.

A Multidisciplinary QI Initiative to Improve OR-ICU Handovers.

: Background: Handover from the operating room (OR) staff to the ICU staff is a critical transition time for patients, in which the potential for error and miscommunication is high. Therefore, minimization of extraneous interruptions during the exchange of crucial information between the anesthesia and surgical teams and the nursing, respiratory therapy, and medical teams is imperative. OBJECTIVES: The aim of this quality improvement (QI) initiative was, first, to examine the impact of a standardized handover process between the OR and the ICU on process and information-sharing errors, and second, to examine provider satisfaction with the handover process. METHODS: We conducted prospective observations of the handover process before and after implementation of the QI initiative. In the pre-process improvement period, 38 cardiothoracic patients were observed during handover. In the post-process improvement period, 38 patients were observed after implementation of the newly developed, standardized handover process and communication template. Provider satisfaction surveys were distributed at each observation during the pre- and post-process improvement periods. RESULTS: Compared with the pre-process improvement period, there was a significant decrease in interruptions during report in the post-process improvement period (1.7 ± 1.1 to 0.13 ± 0.34). There were also significantly fewer handover process errors (6.1 ± 2.8 to 1.7 ± 1.5), and fewer information-sharing errors (5.2 ± 2.7 to 2.3 ± 1.5). Average report time increased slightly, from 13.2 ± 6.8 minutes to 14.6 ± 3.8 minutes, but the increase was not significant. A total of 211 provider satisfaction surveys were completed in the pre-process improvement period and 95 in the post-process improvement period. Providers in all disciplines completed surveys in both time periods, and there was no significant difference in the percentage of respondents from any discipline. Responses to the following survey items showed significant improvement in the post-process improvement period: surgery report was satisfactory, anesthesia report was satisfactory, could hear all the report, pre-op anesthesia information was helpful, and start and end of handover were clear. Post-process improvement as well, more respondents disagreed that the person handing off the patient was under time pressure and that the person taking on responsibility for the patient was under time pressure. CONCLUSION: A standardized OR-ICU handover process developed by a multidisciplinary team decreased handover process and information-sharing errors and increased provider satisfaction, with no significant increase in handover time.

Comparison of nasal and forehead oximetry accuracy and pressure injury in critically ill patients.

BACKGROUND: In critically ill patients, clinicians can have difficulty obtaining accurate oximetry measurements. OBJECTIVE: To compare the accuracy of nasal alar and forehead sensor measurements and incidence of pressure injury. METHODS: 43 patients had forehead and nasal alar sensors applied. Arterial samples were obtained at 0, 24, and 120 hours. Oxygen saturations measured by co-oximetry were compared to sensor values. Skin was assessed every 8 hours. RESULTS: Oxygen saturations ranged from 69.8%-97.8%, with 18% of measures < 90%. Measurements were within 3% of co-oximetry values for 54% of nasal alar compared to 35% of forehead measurements. Measurement failures occurred in 6% for nasal alar and 22% for forehead. Three patients developed a pressure injury with the nasal alar sensor and 13 patients developed a pressure injury with the forehead sensor (χ2 = 7.68; p = .006). CONCLUSIONS: In this group of patients with decreased perfusion, nasal alar sensors provided a potential alternative for continuous monitoring of oxygen saturation.

Discrepancies in measuring bladder volumes with bedside ultrasound and bladder scanning in the intensive care unit: A pilot study.

OBJECTIVE: Intensive care unit patients are at risk for catheter-associated urinary tract infection. Earlier removal of catheters may be possible with accurate measurement of bladder volume. The purpose was to compare measured bladder volumes with bedside ultrasound, bladder scanner, and urine volume. DESIGN: Prospective correlational descriptive study. SETTING: Surgical/trauma intensive care unit and medical intensive care unit. PATIENTS: Renal dialysis patients with less than 100 ml of urine in 24 h prior to urinary catheter removal and patients with suspected catheter obstruction. MEASUREMENTS AND MAIN RESULTS: A physician trained in ultrasound and an advanced practice registered nurse trained in bladder scanning measured bladder volume; each blinded to the other's measurement. Device used first (ultrasound or bladder scanner) alternated daily. The intensive care unit team determined need for intermittent catheterization or treatment for suspected obstruction. Fifty-one measurements from 13 patients were obtained with results reported in milliliters. Ultrasound measurements were a mean volume of 72.1 ± 127 (range: 1.7-666) and the bladder scanner measurements were 117 ± 131 (0-529). On six occasions in five dialysis patients, urine volume measurement was available. The mean difference in ultrasound-urine volume mean difference was 0.5 ± 37.8 (range: -68 to 38.2) and the bladder scanner-urine volume was 132 ± 167 (-72 to 397). Two patients with suspected catheter obstructions had ultrasound, bladder scanner, urine volume measurements, respectively: (1) 539, 51, >300 (began voiding before catheter replaced); (2) 666, 68, 1000 with catheter replacement. Conditions leading to greatest differences were obesity, indwelling catheter and ascites. CONCLUSIONS: These results demonstrate the inaccuracy of the bladder scanner. Ultrasound measurements appear more accurate. To remove urinary catheters in patients with minimal to low urine output, serial ultrasound measurements can be used to monitor bladder volumes and return of renal function.

Effect of chlorhexidine/silver sulfadiazine-impregnated central venous catheters in an intensive care unit with a low blood stream infection rate after implementation of an educational program: a before-after trial.

BACKGROUND: Current guidelines recommend using antiseptic- or antibiotic-impregnated central venous catheters (CVCs) if, following a comprehensive strategy to prevent catheter-related blood stream infection (CR-BSI), infection rates remain above institutional goals based on benchmark values. The purpose of this study was to determine if chlorhexidine/silver sulfadiazine-impregnated CVCs could decrease the CR-BSI rate in an intensive care unit (ICU) with a low baseline infection rate. METHODS: Pre-intervention and post-intervention observational study in a 24-bed surgical/trauma/burn ICU from October, 2002 to August, 2005. All patients requiring CVC placement after March, 2004 had a chlorhexidine/silver sulfadiazine-impregnated catheter inserted (post-intervention period). RESULTS: Twenty-three CR-BSIs occurred in 6,960 catheter days (3.3 per 1,000 catheter days)during the 17-month control period. After introduction of chlorhexidine/silver sulfadiazine-impregnated catheters, 16 CR-BSIs occurred in 7,732 catheter days (2.1 per 1,000 catheter days; p = 0.16). The average length of time required for an infection to become established after catheterization was similar in the two groups (8.4 vs. 8.6 days; p = 0.85). Chlorhexidine/silver sulfadiazine-impregnated catheters did not result in a statistically significant change in the microbiological profile of CR-BSIs, nor did they increase the incidence of resistant organisms. CONCLUSIONS: Although chlorhexidine/silver sulfadiazine-impregnated catheters are useful in specific patient populations, they did not result in a statistically significant decrease in the CR-BSI rate in this study, beyond what was achieved with education alone.