Nursing workload assessment in an intensive care unit: A retrospective observational study using the Nursing Activities Score

Background

Nursing Activities Score (NAS) is a promising tool for calculating the nursing workload in intensive care units (ICU). However, data on intensive care nursing activities in Portugal are practically non-existent.

Aim

To assess the nursing workload in a Portuguese ICU using the NAS.

Study Design

Retrospective cohort study developed throughout the analysis of the electronic health record database from 56 adult patients admitted to a six-bed Portuguese ICU between 1 June–31 August 2020. The nursing workload was assessed by the Portuguese version of the NAS. The study was approved by the Hospital Council Board and Ethics Committee. The study report followed the STROBE guidelines.

Results

The average occupancy rate was 73.55% (±16.60%). The average nursing workload per participant was 67.52 (±10.91) points. There was a correlation between the occupancy rate and the nursing workload. In 35.78% of the days, the nursing workload was higher than the available human resources, overloading nurse staffing/team.

Conclusions

The nursing workload reported follows the trend of the international studies and the results reinforce the importance of adjusting the nursing staffing to the complexity of nursing care in this ICU. This study highlighted periods of nursing workload that could compromise patient safety.

Relevance to Clinical Practice

This was one of the first studies carried out with the NAS after its cross-cultural adaptation and validation for the Portuguese population. The nursing workload at the patient level was higher in the first 24 h of ICU stays. Because of the ‘administrative and management activities’ related to the ‘patient discharge procedures’, the last 24 h of ICU stays also presented high levels of nursing workload. The implementation of a nurse-to-patient ratio of 1:1 may contribute to safer nurse staffing and to improve patient safety in this Tertiary (level 3) ICU.     

综合重症监护治疗病房患者发生腹泻的相关因素分析

目的 分析综合重症监护治疗病房(ICU)患者发生腹泻的相关因素,以指导临床制订最佳治疗方案。方法对2001年1月-2002年12月入住山东省聊城市人民医院综合ICU的危重患者共735例进行回顾性分析,结合文献,综合评价ICU内腹泻发生的原因。结果 735例中,入住ICU前无腹泻,入住24 h后发生腹泻者为86例,发生率为11.70％。引起腹泻的原因主要为:不适当肠内营养51例次(占59.30％),肠道感染18例次(占20.93％),滥用广谱抗生素15例次(占17.44％),大量使用胃肠动力药物11例次(占12.79％),与饥械通气有关者5例次(占5.81％)。而且综合ICU内发生腹泻患者的年龄[平均(57.71±13.40)岁]、急性生理学与慢性健康状况Ⅱ评分[平均(21.51±4.90)分]及住ICU时间[平均(8.0±1.2)d]均明显高于同期入住综合ICU未发生腹泻患者[分别为(51.20±11.31)岁,(12.01±1.20)分和(4.0±1.0)d,P均<0.05],并且发生腹泻的原因不同于普通病房患者引起腹泻的病因。结论 综合ICU患者发生腹泻有其特点和原因,应予以高度重视。     

Nursing home patients in the intensive care unit: Risk factors for mortality

OBJECTIVE: To determine intensive care unit (ICU) admission characteristics predictive of mortality among older nursing home residents. DESIGN: Retrospective cohort study. SETTING: A 725-bed teaching nursing home and two teaching-hospital ICUs. PATIENTS: One hundred twenty-three nursing home residents > or =75 yrs admitted to the ICU between July 1, 1999, and September 30, 2003. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Characteristics of nursing home residents admitted to the ICU were identified by medical record review at the nursing home and the hospital. Additionally, the minimum data set was used to calculate preadmission functional status using the Activities of Daily Living-Long Form (ADL-L) and cognitive status with the Cognitive Performance Scale (CPS). Our primary outcomes were hospital mortality and mortality within 90 days of ICU admission. The nursing home residents admitted to the ICU were old (87.7 +/- 5.4 yrs) with impaired cognition (CPS 2.8 +/- 1.7, range 0-6, where 6 = most impaired) and moderately dependent function (ADL-L 14.5 +/- 9.4, range 0-28, where 28 = total dependence). Of the 123 patients, 33 (27%) died in the hospital, whereas 90 (73%) survived to hospital discharge. Acute Physiology and Chronic Health Evaluation (APACHE) III score was independently associated with significantly increased odds of hospital mortality (adjusted odds ratio 1.04; 95% confidence interval 1.02, 1.07). Among the 90 patients who survived to return to the nursing home, 34 (37.8%) died within 90 days. Cox regression demonstrated that higher APACHE III score (adjusted risk ratio 1.02; 95% confidence interval 1.01, 1.04) and increasing functional dependency before ICU admission (adjusted risk ratio 1.6; 95% confidence interval 1.05, 2.57, per ADL-L quartile) were independently associated with increased mortality rate within 90 days. CONCLUSIONS: Among vulnerable elderly nursing home residents, higher APACHE III score is independently associated with increased hospital mortality rate and mortality within 90 days. Among hospital survivors, impaired functional status is independently associated with increased mortality rate within 90 days.     

Nurses' stress factors in the intensive care unit.

To identify the origins to stress as preceived by ICU nurses, stressful situations in the intensive care unit were identified and ICU nurses were asked to rank order them. Situations pertaining to the physical workload, death of a patient, and communication problems with physicians and nursing administrators were ranked most highly stressful. Nursing educators and nursing administrators can make changes and adjustments to lessen these stressors.     

急诊科重症监护病房患者死亡的相关因素分析

目的 探讨急诊科重症监护病房患者死亡的相关因素.方法 上海交通大学医学院附属第九人民医院EICU病房2005年2月至2007年1月共收治患者450例,生存组356例和死亡组94例.对年龄、性别、APACHEⅡ评分、GCS评分、白蛋白、C-反应蛋白、基础疾病、死亡原因以及院内感染等因素进行分析比较.数据以均数±标准差((x)±s)表示,计数资料采用两独立样本的t检验,两组合并基础疾病数比较采用Radit检验,两组发生院内感染率比较采用χ2检验.P＜0.05为差异有统计学意义.结果 死亡组较生存组年龄大(P=0.002)、合并基础疾病数多(P＜0.05)、APACHEⅡ评分高(P＜0.01)以及GCS评分低(P＜0.01).死亡组血清白蛋白浓度低(P=0.006)、c-反应蛋白值高(P＜0.01)、合并有院内感染多(P=0.046).主要的死亡原因为呼吸衰竭和多脏器功能衰竭.结论 对危重患者病情进行预后评估,有利于采取有效措施,降低病死率.     

重症监护室患者尊严现状及其相关因素调查

目的调查重症监护室患者尊严的现状,并分析其相关因素。方法选取120例重症监护室患者,应用患者尊严量表进行调查。结果患者尊严量表总分为(72.88±18.00)分,患者尊严丧失普遍存在,其中,轻度尊严丧失占14.17%,中度尊严丧失占43.33%,重度尊严丧失占38.33%,非常严重尊严丧失占4.17%。患者年龄与患者尊严总分呈正相关(P0.05);主要照顾者的健康状况、家庭和睦状况是患者尊严丧失的重要影响因素。结论重症监护室患者尊严状况较差,普遍存在尊严丧失,提示应采取有效措施,提高患者的尊严水平。     

Nursing interventions in palliative care in the intensive care unit: A systematic review

ContextPatients in palliative care are found in different places where care is provided, including the intensive care environment with important role of the nursing staff.ObjectiveThe aim of this systematic review was to answer the following question: which nursing interventions are aimed to the palliative care patients who are in the intensive care unit (ICU).Data sourcesUS National Library of Medicine (PUBMED), Virtual Health Library (BVS), SciELO, The Cochrane Library (Cochrane) and Lilacs databases were used.Data extractionAfter applying inclusion and exclusion criteria in accordance with the PRISMA method, a total of 36 entries published between 2010 and 2020 were used.Data analysisThe records extracted were analyzed from a qualitative approach, so no statistical analysis was carried out.ResultsThe findings demonstrated that the interventions that focus on promoting the patient's autonomy and respect their needs on ICU involves effective communication, promoting shared decision with patient and family, individualize care for each patient including the family on the daily care and decisions, maintaining basic nursing care as hygiene and comfort and encouraging self-care, as well as the involvement of nursing palliative care specialists the care is important. Other interventions included promoting a continuing education program for the nursing staff and other professionals involved in caring for patients in palliative care at ICU.ConclusionThis review highlighted the need for specific nursing interventions aimed at palliative care patients at ICU to promote patient autonomy and the focus on patient needs, always sharing decisions with the patient and family. However, it showed that there is a need for the continuous training of the nursing staff because factors such as the nurses’ lack of technical-scientific knowledge and, concomitantly, the absence of a standardized and specific intervention model linked to a bureaucratic system, make it difficult to carry out a specialized care for this type of patient.     

Cardiorespiratory arrest in the intensive care unit: theoretical considerations on factors related with iatrogenic events

The attendance of Cardiopulmonary Resuscitation (CPR) demands rapidity, efficiency, scientific knowledge and technical ability. Still, an adequate infra structure is vital as well as the accomplishment of an harmonic and synchronized work and team performance, in order to promote the patient's backup. Iatrogenic factors related to attendance of CPR in the Intensive Care Unit may be due to professional inexperience, insufficient staff and problems with material or equipments. Thus, the team must be prepared to assist the patient efficiently, as resuscitation should restore the life process and not prolong the death process.     

静脉留置针在新生儿重症监护病房中的应用护理

<正>静脉输液在新生儿重症监护病房是必不可少的治疗手段。在没有特殊原因的情况下,我们给每一位住院的新生儿置入留置静脉针,一方面可以减少静脉穿刺的次数,保护新生儿的静脉,减轻其痛苦;另一方面也为新生儿急救打开了一条绿色通道,有利于方便、快捷、及时的抢救用药。影响新生儿静脉留置针保留时间的主要问题是脱管和堵塞,其次是液体外渗和静脉炎的发生。因此,其护理观察尤为重要。现将护理体会报告如下。     

重症监护病房呼吸机相关性肺炎影响因素的分析

呼吸机相关性肺炎(ventilator-associated pneumonia,VAP)是指原无肺部感染的呼吸衰竭患者,在气管插管机械通气治疗后48h或原有肺部感染用呼吸机48h后发生新的病情变化,临床高度提示为一次新的感染,并经病原学证实,或在人工气道拔管48h以内发生的肺部感染[1]。VAP是机械通气(me     

急诊重症监护病房患者的护理管理

目的探讨急诊及重症监护病房（ICU）监护患者的护理管理。方法对514例急诊ICU监护患者的临床护理管理进行回顾性分析。结果514例急诊ICU监护患者在护士的密切观察和严格护理管理下，家属满意度为99％。结论加强急诊ICU监护患者的护理管理，是减少患者在住院期间护理差错和纠纷的关键，值得临床推广。     

Predisposing factors for hypoglycemia in the intensive care unit

OBJECTIVE: The introduction of strict glycemic control in the intensive care unit has increased the risk for hypoglycemia. In this study we examined the association between predefined circumstances and the occurrence of hypoglycemia in the intensive care unit. DESIGN:: Retrospective cohort study. SETTING: Academic medical center. PATIENTS: All episodes of hypoglycemia (glucose value <45 mg/dL) in our intensive care unit between September 2002 and September 2004 were identified. Presence of predefined circumstances previously associated with hypoglycemia was scored around the moment of hypoglycemia using a patient data management system and in-hospital charts. Patients with a first hypoglycemic event were contrasted to controls from the same cohort, who were matched for time since admission, to correct for the effect of length of stay. Data were analyzed using conditional logistic regression analysis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 2,272 patients, 156 (6.9%) experienced at least one episode of hypoglycemia. Continuous venovenous hemofiltration with bicarbonate-based substitution fluid (odds ratio [OR], 14; 95% confidence interval [CI], 1.8-106), a decrease of nutrition without adjustment for insulin infusion (OR, 6.6; 95% CI, 1.9-23), diabetes mellitus (OR, 2.6; 95% CI, 1.5-4.7), insulin use (OR, 5.3; 95% CI, 2.8-11), sepsis (OR, 2.2; 95% CI, 1.2-4.1), and inotropic support (OR, 1.8; 95% CI, 1.1-2.9) were associated with hypoglycemia. Simultaneous octreotide and insulin use (OR, 6.0; 95% CI, 0.72-50) may also be associated with hypoglycemia. Gastric residual during enteral nutrition without adjusting insulin infusion, liver failure, continuous venovenous hemofiltration with lactate-based substitution fluid, diminished glomerular filtration rate, dose diminishment of glucocorticoids or catecholamines, and use of beta-blocking agents were not associated with hypoglycemia. Adjusting for age, gender, and Acute Physiology and Chronic Health Evaluation II score at admission did not materially change ORs. CONCLUSION: Use of bicarbonate-based substitution fluid during continuous venovenous hemofiltration, a decrease of nutrition without adjustment for insulin infusion, a prior diagnosis of diabetes mellitus, sepsis, and need for inotropic support were found to be associated with hypoglycemia. Simultaneous use of insulin and octreotide may be associated with hypoglycemia.     

Constipation in intensive care unit: Incidence and risk factors

Purpose

Although gastrointestinal motility disorders are common in critically ill patients, constipation and its implications have received very little attention. We aimed to determine the incidence of constipation to find risk factors and its implications in critically ill patients

Materials and Methods

During a 6-month period, we enrolled all patients admitted to an intensive care unit from an universitary hospital who stayed 3 or more days. Patients submitted to bowel surgery were excluded.

Results

Constipation occurred in 69.9% of the patients. There was no difference between constipated and not constipated in terms of sex, age, Acute Physiology and Chronic Health Evaluation II, type of admission (surgical, clinical, or trauma), opiate use, antibiotic therapy, and mechanical ventilation. Early (<24 hours) enteral nutrition was associated with less constipation, a finding that persisted at multivariable analysis (P < .01). Constipation was not associated with greater intensive care unit or mortality, length of stay, or days free from mechanical ventilation.

Conclusions

Constipation is very common among critically ill patients. Early enteral nutrition is associated with earlier return of bowel function.     

Enteral tube feeding in the intensive care unit: factors impeding adequate delivery.

OBJECTIVE: To evaluate those factors that impact on the delivery of enteral tube feeding. DESIGN: Prospective study. SETTING: Medical intensive care units (ICU) and coronary care units at two university-based hospitals. PATIENTS: Forty-four medical ICU/coronary care unit patients (mean age, 57.8 yrs; 70% male) who were to receive nothing by mouth and were placed on enteral tube feeding. INTERVENTIONS: Rate of enteral tube feeding ordered, actual volume delivered, patient position, residual volume, flush volume, presence of blue food coloring in oropharynx, and stool frequency were recorded every 4 hrs. Duration and reason for cessation of enteral tube feeding were documented. MEASUREMENTS AND MAIN RESULTS: Physicians ordered a daily mean volume of enteral tube feeding that was 65.6% of goal requirements, but an average of only 78.1% of the volume ordered was actually infused. Thus, patients received a mean volume of enteral tube feeding for all 339 days of infusion that was 51.6% of goal (range, 15.1% to 87.1%). Only 14% of patients reached > or = 90% of goal feeding (for a single day) within 72 hrs of the start of enteral tube feeding infusion. Of 24 patients weighed before and after, 54% were noted to lose weight on enteral tube feeding. Declining albumin levels through the enteral tube feeding period correlated significantly with decreasing percent of goal calories infused (p = .042; r2 = .13). Diarrhea occurred in 23 patients (52.3%) for a mean 38.2% of enteral tube feeding days. In >1490 bedside evaluations, patients were observed to be in the supine position only 0.45%, residual volume of >200 mL was found 2.8%, and blue food coloring was found in the oropharynx 5.1% of the time. Despite this, cessation of enteral tube feeding occurred in 83.7% of patients for a mean 19.6% of the potential infusion time. Sixty-six percent of the enteral tube feeding cessations was judged to be attributable to avoidable causes. CONCLUSIONS: The current manner in which enteral tube feeding is delivered in the ICU results in grossly inadequate nutritional support. Barely one half of patient caloric requirements are met because of underordering by physicians and reduced delivery through frequent and often inappropriate cessation of feedings.