Experiences of moral distress in a COVID-19 intensive care unit: A qualitative study of nurses and respiratory therapists in the United States.

The COVID-19 pandemic has placed extraordinary stress on frontline healthcare providers as they encounter significant challenges and risks while caring for patients at the bedside. This study used qualitative research methods to explore nurses and respiratory therapists' experiences providing direct care to COVID-19 patients during the first surge of the pandemic at a large academic medical center in the Northeastern United States. The purpose of this study was to explore their experiences as related to changes in staffing models and to consider needs for additional support. Twenty semi-structured interviews were conducted with sixteen nurses and four respiratory therapists via Zoom or by telephone. Interviews were transcribed verbatim, identifiers were removed, and data was coded and analyzed thematically. Five major themes characterize providers' experiences: a fear of the unknown, concerns about infection, perceived professional unpreparedness, isolation and alienation, and inescapable stress and distress. This manuscript analyzes the relationship between these themes and the concept of moral distress and finds that some, but not all, of the challenges that providers faced during this time align with previous definitions of the concept. This points to the possibility of broadening the conceptual parameters of moral distress to account for providers' experiences of treating patients with novel illnesses while encountering institutional and clinical challenges.

Intensive care unit nurses living through COVID-19: A qualitative study.

AIMS: To understand how nurses experience providing care for patients hospitalized with COVID-19 in intensive care units. BACKGROUND: As hospitals adjust staffing patterns to meet the demands of the pandemic, nurses have direct physical contact with ill patients, placing themselves and their families at physical and emotional risk. METHODS: From June to August 2020, semi-structured interviews were conducted. Sixteen nurses caring for COVID-19 patients during the first surge of the pandemic were selected via purposive sampling. Participants worked in ICUs of a quaternary 1,000-bed hospital in the Northeast United States. Interviews were transcribed verbatim, identifiers were removed, and data were coded thematically. RESULTS: Our exploratory study identified four themes that describe the experiences of nurses providing care to patients in COVID-19 ICUs during the first surge: (a) challenges of working with new co-workers and teams, (b) challenges of maintaining existing working relationships, (c) role of nursing leadership in providing information and maintaining morale and (d) the importance of institutional-level acknowledgement of their work. CONCLUSIONS: As the pandemic continues, hospitals should implement nursing staffing models that maintain and strengthen existing relationships to minimize exhaustion and burnout. IMPLICATIONS FOR NURSING MANAGEMENT: To better support nurses, hospital leaders need to account for their experiences caring for COVID-19 patients when making staffing decisions.

Encountering the social determinants of health on a COVID-19 ICU: Frontline providers' perspectives on inequality in a time of pandemic.

Efforts to improve health equity may be advanced by understanding health care providers' perceptions of the causes of health inequalities. Drawing on data from in-depth interviews with nurses and registered respiratory therapists (RRTs) who served on intensive care units (ICUs) during the first surge of the pandemic, this paper examines how frontline providers perceive and attribute the unequal impacts of COVID-19. It shows that nurses and RRTs quickly perceived the pandemic's disproportionate burden on Black and Latinx individuals and families. Providers attribute these inequalities to the social determinants of health, and also raise questions about how barriers to healthcare access may have made some patients more vulnerable to the worst consequences of COVID-19. Providers' perceptions of inequality and its consequences on COVID-19 ICUs were emotionally impactful and distressing, suggesting that this is a critical moment for offering clinicians practical strategies for understanding and addressing the persistent structural inequities that cause racial inequalities in health.

Ethics Committee Consultation and Extracorporeal Membrane Oxygenation.

RATIONALE: The clinical ethics literature on extracorporeal membrane oxygenation (ECMO) has been focused primarily on identifying hypothetical ethical dilemmas that may arise with the use of this technology. Little has been written on the actual experience with ECMO-related ethical questions. OBJECTIVES: To describe the role of an ethics consultation service during the expansion of a single-center ECMO program in a cardiothoracic surgery intensive care unit (CSICU) and to identify common ethical themes surrounding the use of ECMO. METHODS: We conducted a retrospective, descriptive cohort study of all ECMO ethics consultation cases in the CSICU at a large academic hospital between 2013 and 2015. MEASUREMENTS AND MAIN RESULTS: During the study period, 113 patients were placed on ECMO in the CSICU, 45 (39.5%) of whom were seen by the ethics committee. In 2013, 10 of 46 (21.7%) patients received ethics consults. By 2015, 28 of 30 (93.3%) of patients were seen by ethics consultants. Initial consultation occurred at a median of 2 days (interquartile range, 1-6 d) following initiation of ECMO. The most common ethical issue involved disagreement about the ongoing use of ECMO, which included multiple axes: Disagreement among health care providers, disagreement among surrogates, and disagreement between health care providers and surrogates over stopping or continuing ECMO. CONCLUSIONS: In our experience with integrating ethics consultation into the routine care of ECMO patients, most of the ethical questions more closely resembled traditional concerns about the appropriate use of any life-sustaining treatment rather than the novel dilemmas imagined in the current literature.

Comparison of temporal to pulmonary artery temperature in febrile patients.

BACKGROUND: As a routine part of clinical care, temperature measurement is a key indicator of illness. With the criterion standard of temperature measurement from the pulmonary artery catheter thermistor (PAT), which insertion of PAT carries significant risk to the patient, a noninvasive method that is accurate and precise is needed. OBJECTIVES: The purpose of this study was to measure the precision and accuracy of 2 commonly used methods of collecting body temperature: PAT considered the criterion standard and the temporal artery thermometer (TAT) in those patients with a temperature greater than 100.4°F. METHODS: This is a repeated-measures design with each patient with a PAT in the intensive care unit acting as their own control to investigate the difference in PAT readings and readings from TAT in the core mode. Accuracy and precision were analyzed. RESULTS: There were 60 subjects, 41 males and 19 females, with mean age of 60.8 years, and 97% (n = 58) were post-cardiac surgery. There was a statistically significant difference between PAT and TAT (101.0°F [SD, 0.5°F] vs 100.5°F [SD, 0.8°F]; bias, -0.49°F; P < .001). Differences in temperature between the 2 methods were clinically significant (ie, >0.9°F different) in 15 of 60 cases (25%). No TAT measurements were 0.9 F greater than the corresponding PAT measurement (0%; 95% confidence interval, 0%-6%). DISCUSSION: These data demonstrate the accuracy of TAT when compared with PAT in those with temperatures of 100.4°F or greater. This study demonstrates that TAT set to core mode is accurate with a 0.5°F lower temperature than PAT. There was 25% in variability in precision of TAT.

Feasibility and safety of combined percutaneous coronary intervention and therapeutic hypothermia following cardiac arrest.

REVIEW: Mild therapeautic hypothermia (MTH) has been associated with cardiac dysrhythmias, coagulopathy and infection. After restoration of spontaneous circulation (ROSC), many cardiac arrest patients undergo percutaneous coronary intervention (PCI). The safety and feasibility of combined MTH and PCI remains unclear. This is the first study to evaluate whether PCI increases cardiac risk or compromises functional outcomes in comatose cardiac arrest patients who undergo MTH. METHODS: Ninety patients within a 6-h window following cardiac arrest and ROSC were included. Twenty subjects (23%) who underwent PCI following MTH induction were compared to 70 control patients who underwent MTH without PCI. The primary endpoint was the rate of dysrhythmias; secondary endpoints were time-to-MTH induction, rates of adverse events (dysrhythmia, coagulopathy, hypotension and infection) and mortality. RESULTS: Patients who underwent PCI plus MTH suffered no statistical increase in adverse events (P=.054). No significant difference was found in the rates of dysrhythmias (P=.27), infection (P=.90), coagulopathy (P=.90) or hypotension (P=.08). The PCI plus MTH group achieved similar neurological outcomes (modified Rankin Scale (mRS)