Practising evidence-based medicine: the design and implementation of a multidisciplinary team-driven extubation protocol.

BACKGROUND: Evidence from recent literature shows that protocol-directed extubation is a useful approach to liberate patients from mechanical ventilation (MV). However, research evidence does not necessarily provide guidance on how to implement changes in individual intensive care units (ICUs). We conducted the present study to determine whether such an evidence-based strategy can be implemented safely and effectively using a multidisciplinary team (MDT) approach. METHOD: We designed a MDT-driven extubation protocol. Multiple meetings were held to encourage constructive criticism of the design by attending physicians, nurses and respiratory care practitioners (RCPs), in order to define a protocol that was evidence based and acceptable to all clinical staff involved in the process of extubation. It was subsequently implemented and evaluated in our medical/ surgical ICU. Outcomes included response of the MDT to the initiative, duration of MV and stay in the ICU, as well as reintubation rate. RESULTS: The MDT responded favourably to the design and implementation of this MDT-driven extubation protocol, because it provided greater autonomy to the staff. Outcomes reported in the literature and in the historical control group were compared with those in the protocol group, and indicated similar durations of MV and ICU stay, as well as reintubation rates. No adverse events were documented. CONCLUSION: An MDT approach to protocol-directed extubation can be implemented safely and effectively in a multidisciplinary ICU. Such an effort is viewed favourably by the entire team and is useful in enhancing team building.

Anticoagulation in continuous renal replacement therapy.

Continuous renal replacement therapy (CRRT) is a specialized intervention that is managed largely by critical care nurses who are educated in the theoretical and practical aspects of the therapy. CRRT is most commonly indicated for hemodynamically unstable patients who have acute renal failure and a narrow margin of tolerance for the rapid fluid shifts associated with traditional dialysis. Although the utilization of CRRT in the critical care setting is becoming more widespread, numerous factors need to be considered before therapy is initiated. The use of anticoagulation is a concern because of the associated risk of bleeding and thrombocytopenia. Nurses at the bedside must be expert in both managing CRRT and assisting in identifying patients who may be at potential risk when this form of treatment is in place. An overview of possible anticoagulants for use in CRRT is outlined in this article.

A review of neuromuscular blockade in the critically ill patient.

The continuous administration of neuromuscular blocking agents is thought to be associated with a number of adverse effects and complications, including post-paralytic syndrome (characterized by persistent paralysis), muscle weakness, and the inability to wean from the ventilator despite discontinuation of the therapy. Consequently, clinical objectives emphasize administering only the dose necessary to optimize the effect of the drug and for the shortest possible time. This article provides an overview of the administration of neuromuscular blocking agents, from the perspective of a critical care pharmacist and critical care nurses. The complexities associated with pharmacological paralysis in critically ill patients warrants the comprehensive approach to care that multidisciplinary team members can provide.

The use of high-frequency oscillatory ventilation in adult ARDS patients.

Current ventilatory objectives for adults with ARDS include maximizing gas exchange while minimizing lung injury. To this end, high-frequency oscillatory ventilation (HFOV), a mechanical ventilation strategy that simultaneously avoids end-inspiratory alveolar overdistension and end-expiratory alveolar collapse, has been recommended. HFOV meets these criteria from a theoretical perspective, however, is without the benefit of a prospective randomized clinical trial of CMV versus HFOV to demonstrate that effect. This article provides an overview of high-frequency oscillation, followed by an illustration of how it was applied in the case of a 43-year-old patient who developed respiratory failure 24 hours post-Caesarean section.

Acute myocardial infarction and the 12-lead ECG.

It is important that critical care nurses are able to identify the location of cardiac muscle ischemia, injury, and infarction on the electrocardiogram. Knowing the site of infarction is essential in anticipating clinical manifestations and, therefore, has implications for the patient's plan of care. This article includes an overview of four sites of infarction: inferior, posterior, anterior, and lateral. The coronary artery source of each, as well as the ECG findings and clinical signs and symptoms are discussed.

Continuous renal replacement therapy: an overview.

Continuous renal replacement therapy is a treatment option that is especially suited to the critical care setting. Greater hemodynamic stability, the ongoing ability to optimize fluid balance, and the potential for clearing inflammatory mediators are among the frequently cited advantages continuous veno-venous dialysis modalities offer over traditional intermittent therapies. The concept is simple: blood is pumped from the patient, anticoagulated, and passed through a porous filter where, depending on the desired goal, fluid and/or solutes are removed. The blood is then returned to the patient, without large fluctuations in electrolyte and acid-base balance or renal hypoperfusion. This article includes a review of acute renal failure, a discussion of the indications for continuous renal replacement therapy, the mechanisms of action of this therapy, and the nursing considerations.

Nursing and the Net.

Web technologies, including intranet and internet applications, have become pervasive throughout society. Applications in healthcare settings are evolving rapidly and clearly demonstrating that professional and departmental activities can be enhanced, streamlined, and supported by this new technology. At Mount Sinai Hospital, Toronto, obvious benefits are being derived from evolving internet and intranet applications that support nursing practice and management. The purpose of this paper is to discuss the advantages of internet/intranet functionality for nurses, and to describe an intranet application designed specifically for the adult critical care unit.

Heart health and gender.

BACKGROUND: Although mortality from cardiovascular diseases is at least as high among women as among men, the notion that such illnesses are gender-specific, afflicting mainly males, continues to influence our present day understanding of heart disease. OBJECTIVE: To compare the average length of stay for men and women admitted to the CCU over a 14-month period. METHOD: All patients admitted to the CCU of a university-affiliated hospital over a 14-month period were included in the study (n = 167). T-test and chi-square were used to analyze means and percentages, respectively. RESULTS: Significantly more men than women gained admittance to the CCU during the time of this study (p < .001). Differences in average length of stay were not statistically significant, however. Similar numbers of men and women underwent cardiac catheterization. CONCLUSIONS: Gender considerations have emerged as a major issue in the diagnosis and treatment of heart disease in women. Although fewer women than men were admitted to the CCU during the study period, similar percentages had invasive interventions performed.

Implementation of an RN/RT-initiated extubation protocol.

Widespread acceptance of the importance of discontinuing ventilator support at the earliest possible opportunity has resulted in a number of efforts to develop a standardized approach to extubation. The implementation of an extubation protocol designed for the medical/surgical intensive care unit of a university-affiliated hospital followed a series of educational sessions that were open to all members of the multidisciplinary team. As part of quality assurance monitoring, data were collected on the first 47 patients who were extubated using these criteria. A clinical outcome was defined as the percentage of patients who required reintubation within 48 hours. The protocol has been well-received by the ICU team and has become an established component of ventilator management.