Impact of Bedside Laparotomy Simulation and Microlearning on Trauma Nurse Role Clarity, Knowledge, and Confidence.

BACKGROUND: The care of patients undergoing low-volume, high-risk emergency procedures such as bedside laparotomy (BSL) remains a challenge for surgical trauma critical care nurses. OBJECTIVES: This study evaluates simulation and microlearning on trauma nurse role ambiguity, knowledge, and confidence in caring for patients during emergency BSL. METHODS: The study is a single-center, prospective pretest-posttest design conducted from September to November 2022 at a Level I trauma center in the Mid-Atlantic United States using simulation and microlearning to evaluate role clarity, knowledge, and confidence among surgical trauma intensive care unit (STICU) nurses. Participants, nurses from a voluntary convenience sample within a STICU, attended a simulation and received three weekly microlearning modules. Instruments measuring role ambiguity, knowledge, and confidence were administered before the simulation, after, and again at 30 days. RESULTS: From the pretest to the initial posttest, the median (interquartile range [IQR]) Role Ambiguity scores increased by 1.0 (1.13) (p < .001), and at the 30-day posttest, improved by 1.33 (1.5) (p < .001). The median (IQR) knowledge scores at initial posttest improved by 4.0 (2.0) (p < .001) and at the 30-day posttest improved by 3.0 (1.75) (p< .001). The median (IQR) confidence scores at initial posttest increased by 0.08 (0.33) (p = .009) and at the 30-day posttest improved by 0.33 (0.54) (p = .01). CONCLUSIONS: We found that simulation and microlearning improved trauma nurse role clarity, knowledge, and confidence in caring for patients undergoing emergency BSL.

A Nurse-Led Implementation Science Specialist Program.

ABSTRACT: A well-known challenge in health care is integrating evidence into practice. Implementation science (IS) is a growing field that promotes the sustainable application of evidence-based practice (EBP) to clinical care. Health care organizations have an opportunity to support sustainable change by creating robust IS infrastructures that engage nurses in the clinical environment. Integrating IS into a nursing shared governance model is an ideal vehicle to empower direct care nurses to sustain EBP. Importantly, an IS infrastructure may also promote nurse retention and increase interdisciplinary collaboration. This article, the first in a series on applying IS, describes how a multisite health care organization developed a systemwide nurse-led IS Specialist program within a shared governance model.

Describing the landscape of integrated clinical educational programs for PAs and NPs.

PURPOSE: Postgraduate clinical training (PCT) has been available to PAs since the 1970s and to NPs since at least 2007. Some programs now enroll PAs and NPs. Although this new training model appears to be expanding, little data about integrated PA/NP programs are available. METHODS: This study examined the PA/NP PCT landscape in the United States. Programs were identified from membership rosters of the Association of Postgraduate Physician Assistant Programs and the Association of Post Graduate APRN Programs. Data (program name, sponsoring institution, location, specialty, accreditation status) were identified from programs' websites. RESULTS: We identified 106 programs at 42 sponsoring institutions. Various specialties, most commonly in emergency medicine, critical care, and surgery, were represented. Few were accredited. CONCLUSIONS: PA/NP PCT is now common, with about half of the programs accepting PAs and NPs. These programs represent a unique form of interprofessional education involving full integration of two professions in the same program and are worthy of further investigation.

A Comparative Survey Study of In-Person Versus Virtual Trauma Peer Review Meetings.

BACKGROUND: The American College of Surgeons Committee on Trauma mandates regular peer review meetings for verified trauma centers. The COVID-19 pandemic forced in-person meetings to transition to an online platform. OBJECTIVE: The objective of this study was to assess the opinions of participants regarding the benefits and negative aspects of the virtual peer review process. We hypothesize that physicians and nurses would prefer a virtual meeting format. METHODS: An anonymous online survey of members of the American Association for the Surgery of Trauma and the Society of Trauma Nurses was distributed in May and June of 2021. Demographic data and Likert scale-based responses were collected using the Research Electronic Data Capture platform. RESULTS: Invitations were sent to 1,726 physicians and 2,912 nurses. In total, 137 (8%) physicians and 141 (5%) nurses completed the survey. Both groups felt that either platform was effective in addressing opportunities for improvement in care. Physicians disagreed with the statement that anonymous online voting improved their ability to more accurately address opportunities for improvement. In total, 108 (79%) physicians and 100 (71%) nurses preferred a hybrid meeting. Only 18 (13%) physicians and 23 (16%) nurses wanted virtual meetings, whereas only 29 (21%) physicians and 36 (26%) nurses wanted in-person meetings going forward. CONCLUSIONS: Virtual and in-person trauma peer review meetings are equally effective in terms of case discussion and identifying opportunities for improvement in care. Given that most people preferred a hybrid meeting, future studies evaluating how best to incorporate and implement this format are needed.

A residency style transition to practice program in trauma and critical care: The George Washington University Hospital experience.

ABSTRACT: Transition to practice programs for nurse practitioners and physician assistants are gaining popularity and becoming more specialized. As these providers seek opportunities to strengthen their clinical skills and bridge the gap from school to practice, it is important to recognize the benefits and barriers of such programs. In this article, The George Washington University Hospital shares its experience in managing a transition to practice program for trauma and critical care.

Authorized Agent-Controlled Analgesia for Pain Management in Critically Ill Adult Patients.

BACKGROUND: Patient-controlled analgesia is commonly used for adult patients requiring parenteral opioid analgesia in the postoperative setting. However, many patients are unable to use patient-controlled analgesia because of physical or cognitive limitations. Authorized agent-controlled analgesia, in which a nurse or family member activates the patient-controlled analgesia device, has been studied in the pediatric population but has received little attention in adults. OBJECTIVE: To evaluate the efficacy of authorized agent-controlled analgesia in critically ill adult patients. METHODS: A retrospective pilot study was conducted involving 46 patients who were placed on an authorized agent-controlled analgesia protocol in a mixed medical/surgical adult intensive care unit. Critical-Care Pain Observation Tool scores were abstracted for the 24 hours before and after initiation of authorized agent-controlled analgesia. Authorized agent-controlled analgesia was administered by nurses only. RESULTS: The mean (SD) change in pain score was -3.4 (2.0) (95% CI, -4.0 to -2.7), representing a 69% decrease in the mean (SD) pain score from before to after initiation of authorized agent-controlled analgesia (4.8 [1.8] vs 1.5 [1.6]; P < .001). When the results were controlled for time, sedative administration, and opioid medication administration, the effect of authorized agent-controlled analgesia initiation on pain scores remained significant (P < .001). CONCLUSIONS: Use of authorized agent-controlled analgesia is associated with a reduction in pain in critically ill patients. Larger studies are warranted to confirm these findings.

Eastern Association for the Surgery of Trauma and Society of Trauma Nurses advanced practitioner position paper: Optimizing the integration of advanced practitioners in trauma and critical care.

Nurse practitioners and physician assistants, collectively known as advanced practitioners (APs), enhance the provision of care for the acutely injured patient. Despite their prevalence, institutions employ, train, and utilize these providers with significant variability. The Eastern Association for the Surgery of Trauma, the Society of Trauma Nurses, and the American Association of Surgical Physician Assistants acknowledge the value of APs and support their utilization in the management of injured and critically ill patients. This position paper offers insight into the history of, scope of practice for, and opportunities for optimal utilization of APs in trauma, critical care, and acute care surgery services.

Critical Care for the Patient With Multiple Trauma.

Trauma remains the leading cause of death worldwide and the leading cause of death in those less than 44 years old in the United States. Admission to a verified trauma center has been shown to decrease mortality following a major injury. This decrease in mortality has been a direct result of improvements in the initial evaluation and resuscitation from injury as well as continued advances in critical care. As such, it is vital that intensive care practitioners be familiar with various types of injuries and their associated treatment strategies as well as their potential complications in order to minimize the morbidity and mortality frequently seen in this patient population.

Improving handover from intensive care to ward medical teams with simple changes to paperwork.

Medical handover has been highlighted by the General Medical Council[1] as a critical step in patient care, ensuring continuity of care, patient safety, and enabling efficient multidisciplinary functioning. Handover between doctors on the intensive care team and the ward teams in the Great Western Hospital on step down was evaluated by assessing discharge summaries and patient notes, and by following up discharged patients. Handover was found to be present only in the minority of patients and documented in none. Simple changes were made to discharge paperwork in the form of a prompt and documentation of to whom handover was made, as well as the creation of space in the daily review sheets for patients with outstanding handover to be completed. The initial audit findings were presented at a local meeting to remind staff of the importance of handover. These simple modifications brought the handover rates up to 100% (n=12). The rates of documentation of handover also rose from 0% to 100%. This quality improvement project serves to demonstrate that carefully targeted, simple changes to practice in identified critical areas can produce dramatic as well as legally and ethically required results in a very short space of time.

Inferior vena cava size is not associated with shock following injury.

BACKGROUND: The inferior vena cava (IVC) collapses with shock but may also be collapsed in volume-depleted patients in the absence of shock. The speed and availability of computed tomography (CT) make IVC measurement an attractive diagnostic modality for shock. The purpose of this study was to determine if IVC size following injury is associated with shock. METHODS: Retrospective data were collected on 272 trauma patients admitted to an adult trauma center from January 1 to December 31, 2012. Patients who met the highest-level activation criteria and underwent an abdominal CT scan during their initial resuscitation were included. All images were reviewed by two attending radiologists, and concordance was assessed using the Pearson correlation coefficient. The transverse (T) and anteroposterior (AP) diameters of the IVC were measured to calculate a T/AP ratio. Analysis of variance and χ were used to assess for a relationship between this ratio and various indices of shock. RESULTS: The mean (SD) age of the study cohort was 50 (21) years, mean (SD) Injury Severity Score (ISS) was 14 (9), 74% were male, and 96% sustained blunt trauma. The overall mean (SD) T/AP ratio was 1.81 (0.68). Patients with a shock index greater than 0.7 were significantly younger (43 [20] years vs. 55 [21] years, p < 0.0001), had a significantly lower mean arterial pressure (88 [15] mm Hg vs. 103 [18] mm Hg, p < 0.0001), and were more likely to be intubated (56% vs. 24%, p < 0.0001). However, IVC T/AP ratio was not significantly different among the cohort. Similarly, there was no association between IVC size and the need for urgent operation, angiography, emergent transfusion, hospital length of stay, or mortality. CONCLUSION: The static degree of IVC collapse is not associated with shock following injury. Therefore, measurement of IVC size by CT scan for patients with a T/AP ratio between 1 and 3.5 is not clinically relevant and cannot be used to predict mortality, shock, or impending shock. LEVEL OF EVIDENCE: Diagnostic test, level III.

Prolonged use of extracorporeal membrane oxygenation as a rescue modality following traumatic brain injury.

A 21-year-old male trauma patient presented after a motor vehicle crash, witnessed massive aspiration and sustained traumatic brain injury. On postinjury day 3, the patient progressed to adult respiratory distress syndrome (ARDS) refractory to all conventional therapies, prompting the use of extracorporeal membrane oxygenation (ECMO). After 5 days of ECMO support and 3 thrombosed oxygenators, systemic anticoagulation was initiated. After 20 days of ECMO, 15 of which required systemic anticoagulation, the patient was decannulated and transferred to a rehabilitation facility. The patient is currently home without any neurological deficits. Although controversial, ECMO may serve a role as a rescue therapy in ARDS when conventional therapies fail in the brain-injured patient.

Successful management of severe flail chest via early operative intervention.

A review on the role of open reduction and internal fixation of flail chest injuries is presented. A 37-year-old woman involved in a motorcycle crash sustained comminuted rib fractures on her right 3rd through 12th ribs. On postinjury day 2, the patient's fifth through ninth ribs were surgically reduced and plated. Later that same day, the patient was successfully weaned from mechanical ventilation and experienced a rapid improvement in incentive spirometry volumes. Further studies are needed to definitively determine the benefits of rib plating versus conventional treatment. Through our case, we are able to demonstrate successful management of pain and chest wall instability associated with flail chest through the use of rib plating.

Transcatheter aortic valve implantation.

UNLABELLED: Older adults with progressively worsening aortic valve stenosis are limited in their treatment options. Conventional treatment replaces the aortic valve via open-heart surgery, introducing numerous risks and increased mortality in older populations with comorbidities. In recent years, however, transcatheter aortic valve implantation (tAVI) has become a viable option for symptomatic, nonsurgical candidates. Although tAVI is available only to a select population, early randomized and nonrandomized clinical trials are offering insight into the new therapy, with promising results as this treatment continues to evolve. PURPOSE: This article examined the progression of tAVI therapies, from first-generation to third-generation devices and through 4 studies that address the utility of tAVI in symptomatic, nonsurgical candidates, in an effort to prepare nurses in the management of this newly emerging patient population. METHODS: A literature search was conducted of studies within the past 5 years that address transfemoral tAVI in adult populations. Transapical approaches were excluded. RESULTS: Early outcomes demonstrate that successful implantation can improve valvular function and patient functional status. Nurses play a critical role in patient education and monitoring both before and after tAVI. CONCLUSIONS: With increasing life expectancies and a prediction that many aging adults with aortic valve stenosis will be limited to tAVI, nurses need to gain familiarity with this novel therapy and its role in patient outcomes.